Client:
/ (Last Name, First Name)
MR No:
/ KCT0000000000
Visit Date:
/ (Date)
/ Visit Number:
/ 1
/ Visit Type:
/ 00X - ADMISSION WITHOUT OASIS (NON MEDICARE/MEDICAID CLIENTS)
Visit Note Report
/
Client:
/ (Last Name, First Name)
MR No:
/ KCT0000000000
Visit Date:
/ (Date)
/ Visit Number:
/ #
/ Visit Type:
/ 00X – Admission Without Oasis (NON MEDICARE/MEDICAID CLIENTS)
General:
/ (Name) KCT00000000000
Therapy Visit Number:
Visit Date:
/ Visit Number:
/ Visit Type:
/ Branch Code:
/ Billable:
(Date)
/ #
/ 00X - RECERT WITH SKILL (NON MEDICARE/MEDICAID CLIENTS)
/ KCT
/ X
/ #
Agent ID:
/ Agent Name:
/ Mileage Payment Method:
/ Trip Fees:
/ Mileage Start:
/ Mileage End:
/ Mileage:
00000
/ Therapist Name, Credentials
/ NA
/ 0.00
/ 0
/ 0
/ 0
Time:
IN-HOME TIME / BEGAN / 06/19/2013 10:40 AM / INCOMPLETE / 06/19/2013 11:10 AM
DOCUMENTATION TIME / RESUMED / 06/19/2013 11:59 AM / PAUSED / 06/19/2013 12:20 PM
DOCUMENTATION TIME / RESUMED / 06/19/2013 12:21 PM / INCOMPLETE / 06/19/2013 12:32 PM
DOCUMENTATION TIME / RESUMED / 06/19/2013 01:34 PM / COMPLETED / 06/19/2013 02:00 PM
Total In-Home Time: / 0.51 / Hours
Total Doc Time: / 0.95 / Hours
Total Time: / 1.45 / Hours
ICD-10 Diagnoses/Procedures
Order / Item / Code / Description / O/E / O/E Date / Symptom Control / Type
1 / M1020 / (Code) / Diagnosis / Choose Onset / Choose date that shows up as highlighted / Symptom Control is 0-4
Enter the most appropriate rating. For dx you are treating the rating should be a 2 or > / D
*Include ALL MEDICAL diagnoses and YOUR DISCIPLINES TREATING dx
*If a dx is listed before you enter any, then if it is appropriate “validate” it, if it is not appropriate then “delete” it
ASSESSMENT:
PATIENT DATE OF BIRTH
INDICATE PATIENT DATE OF BIRTH:
7/20/2XXX
THERAPY SUBJECTIVE
INDICATE THERAPY SUBJECTIVE
(Include where the evaluation took place, who was present, general observations of child’s participation/supports needed to help with participation, and a statement commenting on the fact that child presented or did not present as he/she normally does to validate/invalidate results)
THERAPY ASSESSMENT/PLAN
INDICATE BACKGROUND AND IDENTIFYING INFORMATION:
(Can cut and paste this bulleted list from reference section or write up as a narrative report, but must include ALL of the following:)
CHRONOLOGICAL AGE (include Adjusted Age if appropriate. Adjust up until the age of 2 and adjust from <37 weeks prematurity)
LIVING IN HOME
PRIMARY LANGUAGE SPOKEN IN THE HOME
PERCENTAGE OF ENGLISH VS. OTHER LANGUAGE SPOKEN:
LANGUAGE SPOKEN MOST OFTEN BY SIBLINGS:
IN WHAT LANGUAGE DOES PATIENT WATCH TV?
IF PATIENT USES WORDS, IN WHAT LANGUAGE ARE THEY SPOKEN?
WAS A TRANSLATOR USED?
DEVELOPMENTAL MILESTONES (report both on speech and motor milestones)
REASON FOR EVALUATION (has to be related to home and community only, not school setting)
PRENATAL HISTORY
BIRTH HISTORY
PERTINENT MEDICAL HISTORY
IF ATTENDING SCHOOL, WHERE AND WHAT GRADE/TYPE OF CLASSROOM
HISTORY OF PRIOR THERAPY RECEIVED
FAMILY HISTORY OF SPEECH, LANGUAGE, AND HEARING DISORDER OR DEVELOPMENTAL DELAY
INDICATE WHICH THERAPY STANDARDIZED ASSESSMENTS WERE PERFORMED: (MARK ALL THE APPLY)
(Choose ALL that you administered) (Any assessment not listed here (for example: BOT-2, SPAT, AIMS, SSI, SAFE, etc.) will be found in the Informal testing section)
TEST DESCRIPTION FOR …..(specific test administered)
(Cut/Paste appropriate test description from the reference section) (Make sure to change the version of the test if applicable)
INDICATE RESULTS OF….(specific test administered):
(Must check ALL of the following. Can also choose OTHER if want to report child’s performance or other information)
Standard Score/Scale Score
Standard Deviation
Percentile
Age Equivalent
(Optional scores are Raw scores, description, etc.)
INDICATE RAW SCORES:
(Enter standard score)
INDICATE STANDARD SCORES:
(Enter standard score)
INDICATE SCORE STANDARD DEVIATION FROM THE MEAN:
(Enter SD of child’s scores NOT SD for the test itself)
INDICATE PERCENTILE RANK:
(Enter percentile rank)
INDICATE AGE EQUIVALENT:
(Enter report percentile rank)
DID YOU PERFORM ANY OTHER INFORMAL TESTING?
YES (Always)
WHAT OTHER INFORMAL TESTING DID YOU PERFORM?
OT:
PERFORMANCE COMPONENTS
REFLEXES:
MUSCLE TONE/STRENGTH/ROM:
SOMATOSENSORY:
VISUAL EFFICIENCY:
VISUAL MOTOR :
FINE/MOTOR/HAND USE:
COORDINATION/MIDLINE/BILATERAL
SKILLS:
GENERAL FUNCTIONAL GROSS
MOTOR SKILLS:
ORAL MOTOR:
PURPOSEFUL DAILY ACTIVITIES
SELF CARE (ADLS): TOILETING,
DRESSING, BATHING, MEALTIME,
COMMUNITY LIVING SKILLS, PLAY
SKILLS, EQUIPMENT
EQUIPMENT: / PT:
MUSCLE TONE/ROM:
SENSATION/PROPIOCEPTION:
REFLEXES:
POSTURE:
STRENGTH:
BALANCE/COORDINATION:
DEVELOPMENTAL SKILLS
(SUPINE, ROLL, PRONE, SIT,
CRAWL, KNEELING, STANDING,
CRUISING AT FURNITURE, ETC.):
FUNCTIONAL
MOBILITY/TRANSFERS:
JUMP/HOP/TIP TOES:
ENDURANCE/ACTIVITY
TOLERANCE:
GAIT/RUN/SKIP:
BALL SKILLS:
EQUIPMENT: / ST:
LANGUAGE SAMPLE INFO:
GENERAL ARTIC INFO
(INTELLIGIBILITY, ETC.)
VOICE
FLUENCY
OBSERVATIONS OF PLAY
GENERAL FEEDING INFO
ORAL MOTOR
IF FEEDING EVAL, MUST INCLUDE:
GROWTH INFO (HEIGHT, WEIGHT,
PERCENTILE, GROWTH CHART)
WHAT IS THE PATIENT EATING?
HOW OFTEN? HOW MUCH?
ANY MBSS INFO (RESULTS AND/OR
RECOMMENDATIONS)
INDICATE IMPRESSIONS AND RECOMMENDATIONS
(The following must be included in narrative form:)
· Qualification statement included why they qualify for therapy
(even if the child does not meet eligibility requirements for the payor, but the therapist would recommend therapy based on testing and clinical observation, you would put a statement of qualification in this area)
· Severity of disorder
(Always put “Patient scores and skills indicate a significant discrepancy between his/her (areas of delay) abilities when compared with child’s chronological age and the abilities of their typical peers)(If scores are severe/profound you may mention this as well)
· Statement of necessity
(If child does not receive intervention, what is he/she at risk of)
· Frequency and Duration of therapy
(Always put “Child is recommended to be seen for 30-45 minute visits per plan of care”)
LONG TERM GOALS:
(Long term goals need to be specific, functional, measurable, and achievable.)
INDICATE STRENGTHS:
(Briefly list areas of strengths identified in the evaluation. This should be a summary only, no new information should be present)
INDICATE WEAKNESSES:
(Briefly list areas of weakness identified in the evaluation. This should be a summary only, no new information should be present)
PARENT PARTICIPATION/HOME PROGRAM
PARENT PARTICIPATION/HOME PROGRAM(INITIAL):
CAREGIVER DEMONSTRATED UNDERSTANDING OF AND IS IN AGREEMENT WITH THE PLAN OF CARE AND
GOALS DISCUSSED BY EVALUATING THERAPIST.
OTHER
PARENT PARTICIPATION/HOME PROGRAM DISCUSSED:
· Home Program
(Summarize the home program as it will look in the upcoming months)
(Add any specific strategy you provided the parent to work on with the child)
HOMEBOUND STATUS
INDICATE HOMEBOUND STATUS:
PATIENT UNDER 21 AND MEETS MEDICAID REQUIREMENTS FOR HOMEBOUND STATUS
VISION/HEARING
VISION/HEARING QUESTIONS
(Choose appropriate response(s))
COORDINATION OF CARE
COORDINATION OF CARE
RECOMMENDATIONS/DISCHARGE PLANNING
PROGNOSIS/DISCHARGE STATEMENT
PHYSICIAN SERVICES
WHO IS THE PATIENT'S PRIMARY CARE PROVIDER? (VERIFY UNDER PATIENT INFORMATION)
(Cut/Paste information from the medical record)
DOES THE PATIENT SEE OTHER SPECIALIST?
(Choose appropriate response(s))
INDICATE NAME OF PHYSICIAN:
(List name of physician, address, phone number)(If contact information then try and list the general location for ex: Children’s Hosp)
LONG TERM GOALS
LONG TERM GOALS
Therapy Goals/Status:
ST/OT/PT THERAPY
(AREA TO TX PER ORDERS)
GOAL
STATUS: (how the patient is performing at the present moment)
GOAL: (where you think they will be performing at the end of 5 months of therapy)
COMMENTS: (add any qualifiers to the general goal bank goal)
CARRYOVER: (n/a on initial evaluation)
SPEECH THERAPY (EXAMPLE)
PRAGMATICS
PARTICIPATE IN SOCIAL ROUTINES
STATUS: 35%
GOAL: 60%
COMMENTS: DEMONSTRATE ABILITY TO GREET OTHERS BY WAVING HELLO AND GOODBYE
Agent Signature:
/ Caregiver Signature:
/ Reason Caregiver Signature Obtained:
Sign your name with credentials / (Signature of person present during evaluation-this should match → info) / (First and last name of person who is present during visit and their relationship to the patient)
(Therapist Name, Credentials)
(Electronically Signed)
98