Transcription of OT Evaluation Clinician - Kinnser Software
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OT Evaluation Clinician - Kinnser Software
Kinnser Software 2016 OT Evaluation Page 1 of 11 OT Evaluation Clinician : Patient Name (Last Name, First Name) & MRN: Mileage: Gender: Agency Name/Branch: M F Date: / / Time In: Time Out: DOB: / / HCPCS Select the home health service type that reflects the primary reason for this visit: (G0152) Services Performed by a qualified occupational therapist (G0158) Services performed by a qualified occupational therapist assistant (G0160) Establishment or delivery of a safe and effective occupational therapy maintenance program Select the location where home health services were provided: (Q5001) Care provided in patient's home/residence (Q5002) Care provided in assisted living facility (Q5009) Care provided in place not otherwise specified (NO) Diagnosis / History Medical Diagnosis: Exacerbation Onset / / OT Diagnosis: Exacerbation Onset / / Relevant Medical History: Prior Level of Functioning: Patient's Goals: Precautions: Homebound?
OT Evaluation Patient Name (Last Name, First Name) & MRN: Date: / /! © Kinnser Software 2016 OT Evaluation Page 2 of 11 Social Supports / Safety Hazards
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