Transcription of Speech/Language Pathology Plan of Treatment Worksheet
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Speech/Language Pathology Plan of Treatment Worksheet
Caring for Your Quality of Life SLP Worksheet Page 1 of 2 Revised: 03/2010 Speech/Language Pathology plan of Treatment Worksheet Patient s Last Name Enter Patient s Last Name First Name Enter Patient s First Name MI HICN Enter SS/HICN Provider Name LifeCare of Florida Provider No 104545 Onset Date ** See Below ** SOC Date = Date of Evaluation Primary Diagnosis(es) From the MD Script, , Parkinson s Disease Treatment Diagnosis(es) The condition you are treating as a result of the primary diagnosis, , Dysphagia Clinical Interview Relevant Background Information (Complete in it s Entirety) The Interview was completed With: Patient Spouse Caregiver Other: _____ Patient Age: _____ Years Primary language (s) Spoken: English Other: _____ Mental Status: Alert Responsive Cooperative Confused Lethargic Impulsive Uncooperative Combative Unresponsive Vision Status: Intact Visual Field Cut Diplopia Other: _____ Hearing Status: Intact Hearing Loss: _____ Functional Impairments that Affect Communication or Feeding: Tremors Neglect Hemiplegia/Hemiparesis Other: _____ _____ Augm
Patient’s Last Name First Name HICN: SLP WorkSheet Page 2 of 2 Revised 03/2010 Rehabilitation History No prior therapy (PT, OT, SLP) appears to have been provided in the past 12 months or
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