Speech/Language Pathology Plan of Treatment …

1 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: _____ _____ Augmentative Communication Devices: None or Describe: _____ The patient resides in a: Home Apartment/Condo ILF ALF or Other: _____ Barriers: _____ The patient lives: Alone or with Spouse Family 24 Hour Care Giver or Other: _____ Family/Support System (Describe): _____ Reason for Referral/Symptom Onset The patient reports that on ___ (exact date) or about ___ (estimated date for a recent onset/gradual decline), the patient experienced.

2 __ New Medical Condition ___ Recent Concerns in swallow function/swallow safety ___ Decline in Communication ___ Cognitive Decline ___ Other (Describe). Specifically the patient reports: Provide detailed narrative summary that has sufficient detail to explain the reason for referral. As a result, he/she has experienced a loss of his/her prior level of function including __ Loss of Range of Motion ___ Decreased Muscle Strength, ___ Decreased Endurance ___ Loss of ADL Independence ___ Other (Describe). His/her level of function declined to the point that Dr. ___ ordered skilled Speech/Language therapy on ____ (Date of MD Referral). Also include in this Section, a relevant quote or statement from the patient/caregiver. Example, I can t even remember the names of my grandchildren or talk to my friends so they can understand me . This helps to paint a picture of the patient and his/her needs and fears.

3 There are situations when the primary diagnosis does not correlate with the Treatment diagnosis and/or the functional impairments. For example, patient may be referred for lumbar stenosis, but the primary complaint for SLP is cognitive decline. In these cases, explain the discrepancy in detail so that the referring MD can review and sign an accurate POT. Prior Level of Function (Describe Diet, Communication, Speech & Voice Function) Describe PLOF as it relates to the current impairments. Example Text: Patient consumed a regular diet and was able to speak without the use of nonsense words during conversation/story telling. Patient s wife reports that patient was adequately able to communicate daily wants and needs and be well understood by his caregivers. Current Level of Function (Summary from SLP Evaluation) The patient has had a significant loss of his communication function as evidenced by reduced respiration for phonation, deteriorating vocal quality and intensity, and difficulties with word finding and appropriate word production.

4 The patient will try to communicate a want or need and ends up using nonsense words that will mimic the word he is trying to say. Longer conversations result in a loss of intelligibility and, thus, a loss of any meaningful language /communication. Swallow function is also compromised as the evaluation documented reduced oral motor function/mastication, wet/gurgly vocal quality and coughing during trials with thin liquids and cookies. Identified Risks (Check all that apply) Patient is at risk for: Swallow Safety Malnutrition Dehydration Aspiration Pneumonia LOS Mortality Patient has safety risks due to Speech/Language impairment(s) cognitive impairments which would place patient at risk in the following situations: Reacting to an emergency Recovering from a fall/calling for help Being home alone Managing Medication Travelling in community Other: _____ 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 The patient has received ___ PT ___ OT ___ SLP in the last 12 months for the ___ current or a ____ previous condition Describe: _Provide details of prior therapy and diagnosis if known.

5 If therapy was provided for the current condition, describe status at time of discharge (if known). The patient is not currently receiving home health services Medical History/Medications (Describe all relevant medical conditions and the date of onset. Include psychosocial diagnosis(es) if present) Co-Morbid Medical Conditions that May Impact Current Condition: Psychosocial Diagnosis that May Impact Current Condition: Medications and side effects if relevant Precautions/Contraindications (For a specific activity and/or intensity of rehabilitation services) Any precautions that need to be observed, , diet, positioning. Speech/Language plan of Treatment Treatment plan : SLP therapy _____ days/wk x _____ weeks for a Treatment duration of _____ hours per visit Initial Certification Period: From:_____ - To: _____ (Maximum Cert Period = 60 Days) Rehabilitation Potential: Guarded Fair Good Excellent (REQUIRED!)

6 Long Term Goals (Number Each Goal): LTGs need to be objective and measurable. Each goal should include a description of the impairment, the level of improvement you hope to reach with Treatment and the functional outcome that will be achieved. EXAMPLE GOALS: 1. Patient will complete compensatory swallow strategies to 90% adequacy with minimum clinician cues for improved swallow safety. 2. Patient will increase respiratory/laryngeal function to 80% adequacy with minimum clinician cues for increased communication function. 3. Patient will increase vocal quality to 90% adequacy with minimum clinician cues for improved communication function. Skilled Intervention to Include: (Include all modalities that are anticipated to be used) 92526 Treatment of Swallow Dysfunction and/or Oral Function for Feeding 92507 Treatment of Speech, language , Voice, Communication or Auditory Processing Disorder Other: _____ Additional Recommendations: OT Evaluation PT Evaluation Social Services Adaptive Equipment: _____ Medical Follow-Up For: _____ Other: _____ Professionals Establishing This plan of Treatment Therapist s Name & Credentials (Please Print) Therapist s Signature Date _____ X_____ _____ 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 .

7 Physician s Name (Please Print) Physician s Signature Date _____ X_____ _____