PT Evaluation / Re­evaluation - Kinnser

1 PT Evaluation / Re evaluationPage 1 of 4PT Evaluation / Re evaluationClinician:MOnsetExacerbationPa tient identity confirmed by clinicianFROM/StrengthResidual weaknessNo hazards identifiedSteps/stairsInadequate lighting, heating and/or coolingInsect/rodent infestationNo gas/electric applianceNarrow or obstructed walkwayCluttered/soiled living areaNo running water, plumbingLack of fire safety devicesOther(specify):Needs assistance for all activitiesRequires max assistance/taxing effort to leave homeUnable to safely leave home unattendedSevere SOB, SOB upon exertionConfusion, unsafe to go out of home aloneBalance/GaitPainSafety TechniquesTransferBed MobilityW/C MobilityPatient Name (Last Name, First Name) & MRN:Date:Time In:Time Out:DOB:Associated mileage:milesGender:Agency Name/Branch:Diagnosis/HistorySocial Supports / Safety HazardsMedical Diagnosis:Date:OnsetExacerbationPT Diagnosis:Prior Level of Functioning:Comments:Other:Functional Limitations:Homebound?

2 Patient Living Situation and Availability of AssistanceCurrent Types of Assistance Received (other than home health staff) Evaluation of Living Situation, Supports, and HazardsComments:BP:Prior:Post:Heart Rate:Prior:Post:Respirations:Prior:Post: O2 Sat:Prior:Post:Safety / Sanitation HazardsPatient lives:Assistance is available:Patient s Goals:Precautions:Relevant Medical History:Date: Evaluation of Cognitive and/or Emotional FunctioningYesalonewith other person(s) in the homearound the clockregular daytimeregular nighttimeRoom AirRoom AirO2 @O2 @viaviaoccasional/short term assistanceno assistance availablein congregate situation, , assisted livingNoVital SignsSpeech:Vision:Hearing:Skin:Edema:Or iented:Muscle Tone:Coordination:Sensation:Endurance:Po sture:PersonPlaceTimePhysical AssessmentPage 2 of 4PT Evaluation / Re evaluationComments:No Pain ReportedRelieved by:Increased by:Interferes with:Primary Site:LocationIntensitySecondary Site:(0 None 10 High)ROMPartShoulderFlexionFlexionFlexio nFlexionExtensionAbduction AdductionInt Rot Ext Rot Elbow ForearmExtensionFingerExtensionWristExte nsionActionRightLeftRightLeftStrengthFle xionPlantar FlexionFlexionKneeExtensionAnkleDorsifle xionNeckExtensionLat FlexionRotationInversionEversionROMPartA ctionRightLeftRightLeftStrengthPronation SupinationFlexionAbduction AdductionInt Rot Ext Rot Hip ExtensionPain AssessmentIndependence Scale KeyDepMax AssistMod AssistMin AssistCGASBAS upervisionMod IndepIndepBed MobilityRolling:Assist LevelAssistive DeviceSupine SitSit SupineComments.

3 LRGaitAssist LevelDistance/Amount Assistive DeviceLevelxxxUnlevelStep/StairsDeviatio ns/Comments:Functional AssessmentPatient Name (Last Name, First Name) & MRN:Date:PT Evaluation / Re evaluationFlexionTrunkRotationExtensionP age 3 of 4PT Evaluation / Re evaluationBalanceAvailable:Other:Needs:1 :2:3:4:5:6:7: Evaluation & Testing DescriptionAssist LevelSittingStandingAble to assume/maintain midline orientationW/CWalkerHospital BedBedside CommodeRaised Toilet SeatTub/Shower BenchFall Risk TestingResultTest 1 Test 2 Test 3 Common fall risk tests include: Tinetti, Functional Reach, Timed Up & Go, One Leg Standing Left, One Leg Standing Right, 4 Square Step, 3 Meter Walk Test, Berg Balance, and Gait Assessment & Skilled Intervention PlanTreatment GoalsTime FramePatient Name (Last Name, First Name) & MRN:Date:PT Evaluation / Re evaluationComments:TransferSit StandAssist LevelAssistive DeviceStand SitBed W/CW/C BedToilet or BSCTub or ShowerCar / VanOtherW/C MobilityAssist LevelLevelUnlevelManeuverComments:Weight Bearing Status:Assistive Device Training (specify):Modalities for Pain Control (specify):CPM (specify):Other (specify):Page 4 of 4PT Evaluation / Re evaluationPhysician NamePhysician SignaturePhysician Phone:Physician Fax:Therapist Signature, Name & Date of Verbal Order for Start of PT TreatmentDate.

4 Date:Name(s):Regarding:Reason:Treatment PlanCare CoordinationDischarge PlanThera ExConference with:Statement of Rehab PotentialTreatment / Skilled Intervention This VisitFrequency & DurationStart Date End DateCurrent Certification Period:Effective DateFrequencyOther Discipline RecommendationsPTAR eviewed Plan of Care, Goals, Frequency, and DirectionOTCOTASNS upervisorOther:OTSTMSWAideTo self care when goals metOther:To self care when max potential achievedTo outpatient therapy with MD approvalOther:Establish or Upgrade HEPT ransfer TrainingGait TrainingBalance TrainingBed Mobility TrainingProsthetic TrainingStairs/Steps TrainingHome Safety TrainingHip Precaution TrainingKnee Precaution TrainingPulmonary Physical TherapyRange of MotionMuscle Re educationUltrasoundElectrotherapyO2 Sat Monitoring PRNE xpected Start Date Expected FrequencyNext Certification Period:Patient Name (Last Name, First Name) & MRN:Date:PT Evaluation / Re evaluatio