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0% done |
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| Diagnoses/CPT | ||||||||||||
| Start Of Care Date |
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Add 1 CPT (Procedure Code)  |
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| Comments | ||||||||||||
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| Home Safety |
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| Mark all that apply |
style="background-color:#CCCCFF">
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| Gross Motor ADLs |
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| Bathing |
style="background-color:#CCCCFF">
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| Toileting |
style="background-color:#CCCCFF">
checked/> 0 Dependent: patient does not participate; needs total assist
checked/> 1 Maximum assist: patient does 25perc of work but needs max support checked/> 2 Moderate assist: patient does 50perc of work but needs mod support checked/> 3 Minimal assist - patient does 75perc of work but needs light support checked/> 4 Contact guard: hold on to the patient checked/> 5 Stand-by assistance or supervision checked/> 6 Independent |
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| Transferring |
style="background-color:#CCCCFF">
checked/> 0 Dependent: patient does not participate; needs total assist
checked/> 1 Maximum assist: patient does 25perc of work but needs max support checked/> 2 Moderate assist: patient does 50perc of work but needs mod support checked/> 3 Minimal assist - patient does 75perc of work but needs light support checked/> 4 Contact guard: hold on to the patient checked/> 5 Stand-by assistance or supervision checked/> 6 Independent |
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| Ambulation |
style="background-color:#CCCCFF">
checked/> 0 Dependent: patient does not participate; needs total assist
checked/> 1 Maximum assist: patient does 25perc of work but needs max support checked/> 2 Moderate assist: patient does 50perc of work but needs mod support checked/> 3 Minimal assist - patient does 75perc of work but needs light support checked/> 4 Contact guard: hold on to the patient checked/> 5 Stand-by assistance or supervision checked/> 6 Independent |
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| Comments | |||
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| Bed Mobility |
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Rolls to side lying position right |
style="background-color:#CCCCFF">
checked/> 0 Dependent: patient does not participate; needs total assist
checked/> 1 Maximum assist: patient does 25perc of work but needs max support checked/> 2 Moderate assist: patient does 50perc of work but needs mod support checked/> 3 minimal assist: patient does 75perc of work but needs light support checked/> 4 Contact guard: hold on to the patient checked/> 5 Stand-by assistance or supervision checked/> 6 Independent |
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Rolls to side lying position left |
style="background-color:#CCCCFF">
checked/> 0 Dependent: patient does not participate; needs total assist
checked/> 1 Maximum assist: patient does 25perc of work but needs max support checked/> 2 Moderate assist: patient does 50perc of work but needs mod support checked/> 3 minimal assist: patient does 75perc of work but needs light support checked/> 4 Contact guard: hold on to the patient checked/> 5 Stand-by assistance or supervision checked/> 6 Independent |
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Rolls prone to supine |
style="background-color:#CCCCFF">
checked/> 0 Dependent: patient does not participate; needs total assist
checked/> 1 Maximum assist: patient does 25perc of work but needs max support checked/> 2 Moderate assist: patient does 50perc of work but needs mod support checked/> 3 minimal assist: patient does 75perc of work but needs light support checked/> 4 Contact guard: hold on to the patient checked/> 5 Stand-by assistance or supervision checked/> 6 Independent |
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Rolls supine to prone |
style="background-color:#CCCCFF">
checked/> 0 Dependent: patient does not participate; needs total assist
checked/> 1 Maximum assist: patient does 25perc of work but needs max support checked/> 2 Moderate assist: patient does 50perc of work but needs mod support checked/> 3 minimal assist: patient does 75perc of work but needs light support checked/> 4 Contact guard: hold on to the patient checked/> 5 Stand-by assistance or supervision checked/> 6 Independent |
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Sits up and maintains balance |
style="background-color:#CCCCFF">
checked/> 0 Dependent: patient does not participate; needs total assist
checked/> 1 Maximum assist: patient does 25perc of work but needs max support checked/> 2 Moderate assist: patient does 50perc of work but needs mod support checked/> 3 minimal assist: patient does 75perc of work but needs light support checked/> 4 Contact guard: hold on to the patient checked/> 5 Stand-by assistance or supervision checked/> 6 Independent |
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| Transfers |
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| Bed |
style="background-color:#CCCCFF">
checked/> 0 Dependent: patient does not participate; needs total assist
checked/> 1 Maximum assist: patient does 25perc of work but needs max support checked/> 2 Moderate assist: patient does 50perc of work but needs mod support checked/> 3 minimal assist: patient does 75perc of work but needs light support checked/> 4 Contact guard: hold on to the patient checked/> 5 Stand-by assistance or supervision checked/> 6 Independent |
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| Toilet |
style="background-color:#CCCCFF">
checked/> 0 Dependent: patient does not participate; needs total assist
checked/> 1 Maximum assist: patient does 25perc of work but needs max support checked/> 2 Moderate assist: patient does 50perc of work but needs mod support checked/> 3 minimal assist: patient does 75perc of work but needs light support checked/> 4 Contact guard: hold on to the patient checked/> 5 Stand-by assistance or supervision checked/> 6 Independent |
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| Chair-Wheelchair |
style="background-color:#CCCCFF">
checked/> 0 Dependent: patient does not participate; needs total assist
checked/> 1 Maximum assist: patient does 25perc of work but needs max support checked/> 2 Moderate assist: patient does 50perc of work but needs mod support checked/> 3 minimal assist: patient does 75perc of work but needs light support checked/> 4 Contact guard: hold on to the patient checked/> 5 Stand-by assistance or supervision checked/> 6 Independent<br /> |
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| Bath-Shower |
style="background-color:#CCCCFF">
checked/> 0 Dependent: patient does not participate; needs total assist
checked/> 1 Maximum assist: patient does 25perc of work but needs max support checked/> 2 Moderate assist: patient does 50perc of work but needs mod support checked/> 3 minimal assist: patient does 75perc of work but needs light support checked/> 4 Contact guard: hold on to the patient checked/> 5 Stand-by assistance or supervision checked/> 6 Independent |
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| Automobile |
style="background-color:#CCCCFF">
checked/> 0 Dependent: patient does not participate; needs total assist
checked/> 1 Maximum assist: patient does 25perc of work but needs max support checked/> 2 Moderate assist: patient does 50perc of work but needs mod support checked/> 3 minimal assist: patient does 75perc of work but needs light support checked/> 4 Contact guard: hold on to the patient checked/> 5 Stand-by assistance or supervision checked/> 6 Independent |
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| To & From Floor |
style="background-color:#CCCCFF">
checked/> 0 Dependent: patient does not participate; needs total assist
checked/> 1 Maximum assist: patient does 25perc of work but needs max support checked/> 2 Moderate assist: patient does 50perc of work but needs mod support checked/> 3 minimal assist: patient does 75perc of work but needs light support checked/> 4 Contact guard: hold on to the patient checked/> 5 Stand-by assistance or supervision checked/> 6 Independent |
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| Comments | ||
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| Balance/Gait |
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| Sitting |
style="background-color:#CCCCFF">
checked/> 5/5 - normal, maintains sitting position against max resistance
checked/> 4/5 - good, maintains sitting position against min-mod resistance checked/> 3/5 - fair, maintains sitting position with guarding assistance checked/> 2/5 - poor, maintains sitting position with max physical assistance checked/> 1/5 - max impaired , less than 25perc accuracy checked/> 0/5 - zero, unable to be placed in sitting position |
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| Standing |
style="background-color:#CCCCFF">
checked/> 5/5 - normal, maintains sitting position against max resistance
checked/> 4/5 - good, maintains sitting position against min-mod resistance checked/> 3/5 - fair, maintains sitting position with guarding assistance checked/> 2/5 - poor, maintains sitting position with max physical assistance checked/> 1/5 - max impaired , less than 25perc accuracy checked/> 0/5 - zero, unable to be placed in sitting position |
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| Berg Score |
style="background-color:ccccff">
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| Tinetti Score |
style="background-color:ccccff">
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| Gait Surface |
style="background-color:#CCCCFF">
checked/> 0 Navigates different surfaces without assistive device
checked/> 1 Navigates different surfaces with assistive device checked/> 2 Navigates flat surfaces without assistive device checked/> 3 Navigates flat surfaces with assistive device checked/> 4 Unable to navigates flat surfaces with or without assistive device |
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| Distance |
style="background-color:#CCCCFF">
checked/> 5 Travels 1 foot per second without assistive device
checked/> 4 Travels 2 feet per second without assistive device checked/> 3 Travels 3 feet per second without assistive device checked/> 2 Travels 1 foot per second with assistive device checked/> 1 Travels 2 feet per second with assistive device checked/> 0 Travels 3 feet per second with assistive device |
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| Comments | ||||||
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| Muscle Strength |
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| Left Upper Extremity |
style="background-color:#CCCCFF">
checked/> 4 Within Normal Limits
checked/> 3 Fair checked/> 2 Poor checked/> 1 Trace checked/> 0 Absent |
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| Left Lower Extremity |
style="background-color:#CCCCFF">
checked/> 4 Within Normal Limits
checked/> 3 Fair checked/> 2 Poor checked/> 1 Trace checked/> 0 Absent |
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| Left Hand |
style="background-color:#CCCCFF">
checked/> 4 Within Normal Limits
checked/> 3 Fair checked/> 2 Poor checked/> 1 Trace checked/> 0 Absent |
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| Right Upper Extremity |
style="background-color:#CCCCFF">
checked/> 4 Within Normal Limits
checked/> 3 Fair checked/> 2 Poor checked/> 1 Trace checked/> 0 Absent |
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| Right Lower Extremity |
style="background-color:#CCCCFF">
checked/> 4 Within Normal Limits
checked/> 3 Fair checked/> 2 Poor checked/> 1 Trace checked/> 0 Absent |
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| Right Hand |
style="background-color:#CCCCFF">
checked/> 4 Within Normal Limits
checked/> 3 Fair checked/> 2 Poor checked/> 1 Trace checked/> 0 Absent |
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| Comments | ||
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| Range of Motion Upper |
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| document range | ||||
| Elbow |
style="background-color:ccccff">
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| Forearm |
style="background-color:ccccff">
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| Wrist |
style="background-color:ccccff">
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| Shoulder |
style="background-color:ccccff">
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| Comments | ||||
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| Range of Motion Lower |
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| document range | |||
| Hip |
style="background-color:ccccff">
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| Knee |
style="background-color:ccccff">
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| Ankle |
style="background-color:ccccff">
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| Cervical Spine |
style="background-color:ccccff">
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| Comments | |||
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| Pain Assessment |
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| Pain Level |
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| Pain Scale |
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| Pain Characteristics |
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| Pain Threshold |
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Rate CURRENT pain treatment effectiveness on a scale* of 1 to 10 (1 = low effectiveness) |
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How long does each treatment work before needing another dose |
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What is patient's opinion of the cause of her/his pain? |
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| Comments | |||||||||||||
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| Other |
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| Shortness of Breath |
style="background-color:#CCCCFF">
checked/> 0 - Never, patient is not short of breath
checked/> 1 - When walking more than 20 feet, climbing checked/> 2 - With moderate exertion checked/> 3 - With minimal exertion or with agitation checked/> 4 - At rest (during day or night) |
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| Joints |
style="background-color:#CCCCFF">
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Adaptive Equipment/ Prosthetics |
style="background-color:#CCCCFF">
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Reason why patient needs devices... |
style="background-color:ccccff">
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General Assessment |
style="background-color:#CCCCFF">
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Rehabilitation Potential |
style="background-color:#CCCCFF">
checked/> 0 - Guarded: minimal improvement in functional status is expected; decline is possible
checked/> 1 - Good: marked improvement in functional status is expected checked/> UK-Unknown |
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| Comments | |||
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