lifecare physical)therapy) plan)of)treatment) pt...lifecare therapy services rehabilitation therapy...
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LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
PT Plan of Treatment Page 1 of 2 Revised: 01/2013
Physical Therapy Plan of Treatment
Patient’s Last Name First Name
MI HICN
Provider Name LifeCare of Florida
Provider No
Onset Date SOC Date
Primary Diagnosis(es) Treatment Diagnosis(es)
Clinical Interview The Interview was completed with: Patient Spouse Caregiver Other: _______________________________________________________________ Patient Age: ___________ Years Mental Status: Alert Oriented x __________ Impaired: _____________________________________________
Living Situation The patient resides in a: Home Apt/Condo ILF ALF or Other: ________________________________________________________________ Accessibility: Level Ramped Steps: _______ To Enter _______ In Home Concerns: ________________________________________________________ The patient lives: Alone or with Spouse Family Caregiver ________________________ (Hours/Days) Other: __________________________________ Who currently helps with ADLs? _____________________________________________________________________________________________________________
Reason for Referral/Symptom Onset
Medical History/Medications Additional Complexities that Impact Care Assistive Device History Prior to the onset of the current condition, Patient utilized: (List equipment used): _______________________________________________________________ Currently Patient utilizes: __________________________________________________________________________________________________________________ Comments (Address safety and effective use of equipment): ______________________________________________________________________________________
Fall History & Risk Assessment Patient has had falls. The last fall occurred on (date): __________________________ Location: ___________________________________________________ which resulted in (Describe injury or condition): ___________________________________________________________________________________________ Patient is at risk for falls due to: Loss of balance Poor postural alignment/control Difficulty walking Freezing when walking Is patient able to call for help? Yes No Comments: ________––_____________________________________________________________________
Rehabilitation History No prior therapy (PT, OT, SLP) appears to have been provided in the past 12 months or, Patient has received PT OT SLP in the last 12 months for the current or a previous condition Describe: __________________________________________________________________________________________________________________________ Patient is not currently receiving home health services
LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
Physical Therapy Plan of Treatment – Page 2
Patient’s Last Name First Name
MI HICN
PT Plan of Treatment Page 2 of 2 Revised: 01/2013
Impact on Function Prior Level of Function Independent Required Assistance (Describe) Current Level of Function (Summary from PT Evaluation) Applicable G-‐Code with Severity Modifier (Impairment) Priority Ranking
G-‐Code Functional Area Admission Goal
Instructions: Rank in order of priority from 1-‐6 with only ONE primary limitation which will be the billable code. Document N/A if appropriate.
Code Impairment Level (0-‐100%)
Code Impairment Level (0-‐100%)
________ Mobility: Walking & Moving Around G8978 ________ G8979 ________ ________ Changing & Maintaining Body Position G8981 ________ G8982 ________ ________ Carrying, Moving & Handling Objects G8984 ________ G8985 ________ ________ Self Care G8987 ________ G8988 ________ ________ Other Primary Functional Limitation G8990 ________ G8991 ________ ________ Other Subsequent Functional Limitation G8993 ________ G8994 ________
Physical Therapy Plan of Care Recommended # of Visits for Skilled POC: __________Visits Frequency: _________/week Duration: __________ hours/visit Certification Period: Start: __________________ End: _____________________ (Max 90 days)
Rehabilitation Potential: Excellent Good Fair Guarded Poor Long Term Goals: (Number each goal)
Skilled Intervention to Include 97110 Therapeutic Exercise 97112 Neuromuscular Re-‐Education 97116 Gait Training 97140 Manual Therapy 97542 Wheelchair Training 97761 Prosthetic Training Other: _____________________________________________________________________________________________________________________________
Additional Recommendations OT Evaluation SLP Evaluation Social Services Adaptive Equipment: _____________________________________________________________ Medical Follow-‐Up For: _______________________________________________________________________________________________________________ Other: _____________________________________________________________________________________________________________________________
Professionals Establishing This Plan of Care Therapist Name & Credentials (Please Print) ______________________________________________________
Therapist Signature X_____________________________________________________
Date ____________________
As of the date of this evaluation, I certify the pertinent medical history and the need for skilled services that have been completed in consultation with the evaluating therapist under this plan.
Physician Name (Please Print) ___________________________________________________
Physician Signature X____________________________________________________
Date ____________________
LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
PT Initial Evaluation Page 1 of 2 Revised: 01/2013
MI HICN
Provider Name LifeCare of Florida
Provider No
Onset Date SOC Date
Primary Diagnosis(es) Treatment Diagnosis(es)
Clinical Evaluation
Range of Motion Grossly WFL or Impaired (Check all Areas of Impairment) Cervical Spine Lumbar Spine
Left UE Shoulder Elbow Wrist Hand
Right UE Shoulder Elbow Wrist Hand
Left LE Hip Knee Ankle Foot
Right LE Hip Knee Ankle Foot
ROM Measurements
Muscle Strength Grossly WFL or Impaired (Check all Areas of Impairment) Cervical Spine Lumbar Spine
Left UE Shoulder Elbow Wrist Hand
Right UE Shoulder Elbow Wrist Hand
Left LE Hip Knee Ankle Foot
Right LE Hip Knee Ankle Foot
MMT Measurements
Muscle Tone Grossly WFL or Impaired (Describe Area & Level of Impairment Using Modified Ashworth Scale 0-‐4) Sensation Grossly WFL or Impaired (Describe) Edema Not Present Present (Describe) Pain Not Present Present (Describe using 0-‐10 Visual Analog Scale) Endurance Good Fair Poor (Describe Activity Tolerance in minutes or activity before rest is required) Other Pertinent Clinical Findings
Patient’s Last Name First Name
MI HICN
PT Initial Evaluation Page 2 of 2 Revised: 01/2013
Functional Scoring Guidelines (FIM Score)
7=Independent 6=Modified Independent 5=Supervision 4=Min Assist (25%) 3=Mod Assist (50%) 2=Max Assist (75%) 1=Total Assist (76% or >)
Mobility Assessment Test(s) Administered Clinical Assessment Tinetti Gait/Balance Assessment Other: __________________________________________________
Test Results: Score: ____________ Interpretation: ___________________________________________________________________________ Gait Pattern WFL or Impaired (Describe)
Ambulation FIM Prior LOF FIM Eval LOF Assessment Notes FIM Goal LOF Household __________ __________ _________________________________________________________ __________
Uneven Surface __________ __________ _________________________________________________________ __________
Outdoors/Community __________ __________ _________________________________________________________ __________
Stairs __________ __________ _________________________________________________________ __________
Global FIM Score ________________ ______________ _____________
Total Mobility Impairment Level
PLOF
CLOF
Goal LOF
Changing & Maintaining Body Position Test(s) Administered Clinical Assessment BERG Balance Scale Other: _________________________________________________________
Test Results: Score: ____________ Interpretation: __________________________________________________________________________ Postural Evaluation WFL or Affects Function (Describe) Transfers FIM Prior LOF FIM Eval LOF Assessment Notes FIM Goal LOF Bed/Chair __________ __________ _________________________________________________________ __________
Chair/Stand __________ __________ _________________________________________________________ __________
Toilet __________ __________ _________________________________________________________ __________
Tub/Shower __________ __________ _________________________________________________________ __________
Car __________ __________ _________________________________________________________ __________
Balance
Sitting Unsupported __________ __________ _________________________________________________________ __________
Standing Unsupported __________ __________ _________________________________________________________ __________
Dynamic Balance __________ __________ _________________________________________________________ __________
Challenged Balance __________ __________ _________________________________________________________ __________
Global FIM Score ________________ ______________ _____________
Total Body Position Impairment Level
PLOF
CLOF
Goal LOF
Supplemental Functional Assessment Findings
LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
PT Evaluation Encounter Note Revised: 03/2013
Physical Therapy Evaluation Encounter Note Evaluation Encounter Note
Patient’s Last Name First Name
MI HICN
Provider Name LifeCare of Florida
Provider No
Onset Date SOC Date
Primary Diagnosis(es) Treatment Diagnosis(es)
Billing & Coding Services Rendered Intake Evaluation Skilled Therapy
Intake Information Summary __________ Time _________ Units
97001 PT Evaluation
__________ Time _________ Units
97110 Therapeutic Exercise
__________ Time _________ Units
97112 Neuromuscular Re-‐Education
__________ Time _________ Units
97116 Gait Training
__________ Time _________ Units
97140 Manual Therapy
__________ Time _________ Units
97542 Wheelchair Training
__________ Time _________ Units
Total Time (Minutes)
Total Units
Plan: As per Physical Therapy Plan of Treatment
Time Spent for Care: Time In: ______________________ AM/PM Time Out: ______________________ AM/PM
Patient Certification I certify that I was seen today by the therapist named below and that the time spent for my care is correct.
I understand and agree to the plan of care recommended. I certify that I am not receiving home health services at this time
Patient/Authorized Representative (Please Print) ______________________________________________________
Patient/Authorized Signature X_____________________________________________________
Date ____________________
Provider Certification
Therapist Name & Credentials (Please Print) ___________________________________________________
Therapist Signature X____________________________________________________
Date ____________________