2402 Wayne Memorial Drive, Goldsboro NC 27534-1728, (919) 735-1387

485 Worksheet Addendum

Speech Therapy

Patient Name: DOB: Patient ID:

Office: Visit Frequency:

Certification: Recertification:

ST GENERAL ORDERS
 / SPEECH THERAPY.
 / AUDIOLOGICAL SCREENING.
 / FLUENCY
 / LATENCY RESPONSE.
 / ATTENTION SPAN.
 / ASSESS FOR PATIENT ABILITY TO PERFORM SELF CARE.
 / ASSESS FOR NEGLECT AND OR ABUSE.
 / ASSESS FOR IMPAIRED AUDITORY COMPREHENSION.
 / ASSESS FOR IMPAIRED VERBAL EXPRESSION.
 / ASSESS FOR IMPAIRED NONVERBAL EXPRESSION.
 / ASSESS FOR IMPAIRED READING COMPREHENSION.
 / ASSESS FOR IMPAIRED WRITTEN EXPRESSION.
 / ASSESS FOR IMPAIRED SWALLOWING ABILITY.
 / ASSESS FOR IMPAIRED MOTOR SPEECH ABILITIES.
 / ASSESS FOR IMPAIRED COGNITION.
 / TEACH AUDITORY COMPREHENSION TASKS IN HOME PROGRAM.
 / TEACH USE OF AUGMENTATIVE AND OR NONORAL COMMUNICATION SYSTEM.
 / TEACH VERBAL EXPRESSIVE TASKS IN HOME PROGRAM.
 / TEACH ORAL MOTOR PLANNING TASKS IN HOME PROGRAM.
 / TEACH VISUAL PERCEPTUAL TASKS IN HOME PROGRAM.
 / TEACH READING COMPREHENSION TASKS IN HOME PROGRAM.
 / TEACH WRITTEN EXPRESSIVE TASKS IN HOME PROGRAM.
 / TEACH ORAL EXERCISE PROGRAM.
 / TEACH COGNITIVE TASKS IN HOME PROGRAM.
 / TEACH COMPENSATORY SWALLOWING TECHNIQUES.
 / TEACH MECHANICAL USE AND OR CARE OF ELECTROLARYNX.
 / TEACH HOME SAFETY.
 / TEACH FIRE SAFETY.
 / SPEECH THERAPY TO EVALUATE PATIENT.
 / VOICE DISORDERS TREATMENT.
 / SPEECH ARTICULATION DISORDERS TREATMENT.
 / DYSPHASIA TREATMENTS.
 / LANGUAGE DISORDERS TREATMENTS.
 / SWALLOWING MAINTENANCE PROGRAM.
 / AURAL REHABILITATION.
 / NONORAL COMMUNICATIONS.
 / ESTABLISH CARRYOVER PROGRAM.
 / DO NOT RESUSCITATE.
 / RESUME CARE.
 / RESUME PREVIOUS ORDERS.
 / ON HOLD. PATIENT HOSPITALIZED. RESUME CARE PRN AFTER DISCHARGE.
 / PERFORM AUDITORY COMPREHENSION TASKS AT LEVEL.
 / CONSTRUCT AUGMENTATIVE AND OR MONAURAL COMMUNICATION SYSTEM.
 / PERFORM VERBAL EXPRESSIVE TASKS AT LEVEL.
 / PERFORM ORAL MOTOR PLANNING AT LEVEL.
 / PERFORM VISUAL PERCEPTUAL TASKS AT LEVEL.
 / PERFORM READING COMPREHENSION TASKS AT LEVEL.
 / PERFORM WRITTEN COMPREHENSION TASKS AT LEVEL.
 / PERFORM SWALLOWING PROCEDURE WITH THERMAL APPLICATION
 / PERFORM SWALLOWING PROCEDURE WITH INCREASED SAFETY AND ORAL INTAKE.
 / PERFORM EXERCISES.
 / PERFORM MOTOR SPEECH TASKS.
 / ESTABLISH COMPENSATORY STRATEGIES.
 / PERFORM COGNITION TASKS.
 / PERFORM EXERCISES WITH THE ELECTROLARYNX.
 / PERFORM ALARYNGEAL SPEECH ACTIVITIES.
ST GOALS
IMPAIRED VERBAL EXPRESSION
 / UTILIZE WORD UTTERANCE WITH % ACCURACY.
 / MAINTAIN CONVERSATIONAL TOPIC FOR MINUTES AND CONSECUTIVE SESSIONS.
 / PRODUCE NUMBER SENTENCES IN CONVERSATION ON GIVEN TOPIC.
 / VERBALIZE WANTS AND NEEDS WITH % ACCURACY WITHIN WEEKS.
 / RESPOND USING AUTOMATIC WORDS TO QUESTIONS WITH % ACCURACY.
 / NAME ITEMS IN A CATEGORY.
 / ANSWER WH- QUESTIONS WITH % ACCURACY.
 / VERBALLY STATE PERSONAL INFORMATION WITH % ACCURACY.
 / COMPLETE OPEN ENDED SENTENCES WITH WORD, PHRASE, SENTENCE WITH % ACCURACY.
 / EXPLAIN COMMON IDIOMS/EXPRESSIONS WITH % ACCURACY.
 / STATE SEQUENCE OF STEPS UP TO STEPS.
 / IMITATE WORDS, SENTENCES WITH % ACCURACY.
 / NAME, DESCRIBE OBJECTS/ITEMS/PICTURES WITH % ACCURACY.
 / EXPLAIN SIMILARITIES/DIFFERENCES OF ITEMS WITH % ACCURACY.
 / PERFORM NAMING TASKS WITH % ACCURACY.
 / PRODUCE WORDS, SENTENCES WITH % INTELLIGIBILITY PER 100 WORDS.
 / PRODUCE WORDS, SENTENCES AND CONVERSE WITH <5 STUTTERED WORDS PER 100 WORDS SPOKEN.
IMPAIRED WRITTEN EXPRESSION
 / COPY WITH % ACCURACY WITHIN WEEKS.
 / WRITE WITH % ACCURACY WITHIN WEEKS.
 / PERFORM FORMULATION TASKS WITHIN WEEKS AND % ACCURACY AND LEGIBILITY WITHIN WEEKS.
 / OTHER:
IMPAIRED GESTURAL EXPRESSION
 / INDICATE YES/NO RESPONSES TO QUESTIONS WITH % ACCURACY.
 / INDICATE CHOICE BY POINTING/EYE GAZE WITH % ACCURACY.
 / COMMUNICATE BASIC NEEDS BY POINTING WITH % ACCURACY.
 / INDICATE RESPONSE TO QUESTIONS USING SIGN LANGUAGE IN WEEKS.
 / INDICATE WANTS/NEEDS/IDEAS USING SIGN LANGUAGE IN WEEKS.
 / COMMUNICATE WANTS/NEEDS/IDEAS USING AUGMENTATIVE COMMUNICATION SYSTEM WITHIN WEEKS.
 / OTHER:
IMPAIRED FRAGMATIC EXPRESSION
 / ESTABLISH AND/OR MAINTAIN EYE CONTACT DURING CONSECUTIVE SESSIONS.
 / INITIATE AND MAINTAIN INTERACTION FOR MINUTES DURING CONSECUTIVE SESSIONS.
 / MAINTAIN SENTENCE EXCHANGE FOR TURNS CONSECTUIVE SESSIONS.
 / INITIATE A TOPIC TIMES DURING A SESSION.
 / TERMINATE INTERACTION TIMES DURING SESSIONS.
 / IMPAIRED VOICE/MOTOR SPEECH/ARTICULATION/INTELLIGIBILITY
 / IMITATE ORAL MOVEMENTS WITH REPETITIONS.
 / PRODUCE VOICING ON COMMAND WITH % ACCURACY.
 / IMITATE VOWELS, PHONEMES, SYLLABLES WITH % ACCURACY.
 / PRODUCE PHONEMES IN POSITION(S) IN WORDS, PHRASES, SENTENCE AND CONVERSATION WITH % ACCURACY.
 / CONVERSE WITH % INTELLIGIBILITY AND ACCURACY PER 100 WORDS.
 / RESPOND IN WORDS, PHRASES/SENTENCES USING PACING TECHNIQUE WITH % ACCURACY.
 / SUSTAIN VOWELS FOR SECONDS.
 / PRODUCE VF ADDUCTION EXERCISES WITH REPETITIONS.
 / NECK STRENGTH AND ROM EXERCISES HOLDING SECONDS AND/OR REPETITIONS.
 / PRODUCE NATURAL PITCH AND VOLUME DURING DISCOURSE SESSIONS.
 / PRODUCE LINGUAL MOTOR EXERCISES HOLDING SECONDS, REPEATING TIMES.
 / PRODUCE LIP SENSORY-MOTOR EXERCISES REPEATING TIMES AND/OR HOLDING SECONDS.
 / PRODUCE CHEEK MOTOR EXERCISES HOLDING SECONDS REPEATING TIMES.
 / OTHER:
IMPAIRED INFORMATION PROCESSING
 / RESPOND TO ENVIRONMENTAL SDS DIFFERENTIALLY WITH % ACCURACY.
 / RESPOND TO NAME WHEN CALLED WITH % ACCURACY.
 / DISCRIMINATE MINIMAL PAIRS AND/OR WORDS WITH SIMILAR PHONEME CONTEXT WITH % ACCURACY.
 / INDICATE DISCRIMINATION OF TARGET SDS/WDS IN A SERIES WITH % ACCURACY
 / USE/ADJUST LISTENING DEVICE WITH TOTAL CORRECTNESS.
 / DEMONSTRATE USE/CARE OF HEARING AID.
 / SPEECH READ SINGLE WORDS/PHRASES/SENTENCES USING SPEECH READING SKILLS WITH % ACCURACY.
 / VISUALLY TRACK MOVING OBJECTS IN 180 DEG RADIUS WITH % ACCURACY.
 / LOCATE ITEMS WITHIN EFFECTED VISUAL PLANE WITH % ACCURACY.
 / MATCH NONVERBAL/VERBAL MATERIAL WITH % ACCURACY.
 / MATCH LIKE OBJECTS AND/OR PICTURES WITH % ACCURACY.
 / FOLLOW STEP DIRECTIONS WITH % ACCURACY.
 / IMITATE/MODEL AUDITORIALLY PRESENTED WORDS, PHRASES, SENTENCES WITH % ACCURACY AND TIME DELAY WITH % ACCURACY.
 / COMPREHEND YES/NO/WH-QUESTIONS WITH % ACCURACY.
 / IDENTIFY PART-WHOLE AND/OR WHOLE-PART RELATIONS WITH % ACCURACY.
 / IDENTIFY FUNCTION OBJECT/PICTURE AND/OR OBJECT/PICTURE FUNCTION WITH % ACCURACY.
 / SORT PICTURES/OBJECTS INTO CATEGORIES WITH % ACCURACY.
 / DEMONSTRATE COMPREHENSION OF OPPOSITES/SYNONYMS/HOMONYMS WITH % ACCURACY.
 / FORMULATE QUESTIONS GIVEN INITIAL WORDS WITH % ACCURACY.
 / OTHER:
IMPAIRED READING
 / MATCH SINGLE LETTERS WITH % ACCURACY.
 / RECOGNIZE WRITTEN WORDS BY MATCHING WITH CORRESPONDING PICTURE WITH % ACCURACY.
 / FOLLOW WRITTEN COMMANDS WITH % ACCURACY.
 / READ SENTENCES TO FACILITATE FLUENCY WITH % ACCURACY.
 / ATTEND TO LEFT MARGIN FOR READING TASKS WITH % ACCURACY.
 / PATIENT WILL MATCH WORD WITH CORRESPONDING SENTENCES WITH % ACCURACY.
 / PATIENT WILL ANSWER QUESTIONS RELATED TO TEXT WITH % ACCURACY.
 / OTHER:
IMPAIRED COGNITION
 / ORIENTED TO TIME, PLACE, PERSON WITH % ACCURACY.
 / PERFORM CALCULATIONS NEEDED FOR ADL WITH % ACCURACY.
 / USE PHONE BOOK TO LOCATE ITEMS WITH % ACCURACY.
 / IDENTIFY PERSON, PLACES, TIMES IN RECENT AND/OR REMOTE MEMORIES WITH % ACCURACY.
 / UTILIZE HIGHER LEVEL THINKING SKILLS TO PROBLEM-SOLVE/ANALYZE WITH % ACCURACY.
 / OTHER:
IMPAIRED SWALLOWING ABILITY
 / PATIENT WILL PERFORM EXERCISES WITH REPITITIONS AND/OR HOLD FOR SECONDS.
 / PATIENT WILL CHANGE POSTURE TO FACILITATE SWALLOWING WITHIN WEEKS.
 / PATIENT WILL INCREASE PO INTAKE TO WITHIN WEEKS.
 / PATIENT WILL TOLERATE DIETARY CONSISTENCY AND FLUIDS WITHIN WEEKS WITHOUT SIGNS/SYMPTOMS OF ASPIRATION FOR DAYS.
 / PATIENT AND/OR CAREGIVER WILL INCORPORATE DIETARY MANAGEMENT PROCEDURES (TEXTURES, TEMPERATURES, PRESENTATION) WITHIN WEEKS.
 / PATIENT WILL TOLERATE ORAL STIMULATION DURING PO PROCESS WITH % ACCURACY.
 / PATIENT WILL INCORPORATE COMPENSATORY SWALLOWING PROCEDURES (SUPRAGLOTTIC, VALSALVA MANEUVER, EFFORTFUL SWALLOW, MENDELSOHN MANEUVER, DOUBLE SWALLOW) NEEDED TO ASSIST PROCESS WITHIN WEEKS.
 / OTHER:
HOMEBOUND
 / HOME IS THE APPROPRIATE PLACE FOR CARE DUE TO
 /
  1. DUE TO THE PATIENTS ILLNESS INJURY OR DISABILITY GOING TO AN OUTPATIENT SETTING WOULD CREATE A MEDICAL HARDSHIP BECAUSE ......

 /
  1. GOING TO AN OUTPATIENT SETTING IS CONTRAINDICATED BY THE PATIENTS FRAGILE AND UNSTABLE CONDITION AND THE PHYSICIAN STATES IT WOULD BE UNDESIRABLE OR DETRIMENTAL BECAUSE......

 /
  1. GOING TO AN OUTPATIENT SETTING WOULD INTERFERE WITH THE EFFECTIVENESS OF THE SERVICE BECAUSE......

485 Worksheet Addendum – Skilled NursingPage 1

Rev. 02/06