Lifelong Therapeutics OT Form [591782]

Lifelong Therapeutics / Occupational Therapy
Note Type*

Evaluation10th Visit Progress Note20th Visit Progress Note30th Visit Progress NoteDischarge SummaryRe-evaluationMaintenance Report
Patient Name*

Last NameFirst Name
Location
Apt / Rm
Patient is in private address

Yes
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Info
Primary Contact

First NameLast Name
Contact E-mail
Contact Phone
Date of Birth

MonthDayYear
Primary Insurance
Secondary Insurance
Physician
Physician Phone
Reason for Referral
Subjective
Subjective Comment

Objective Findings 1
Prior Level of Function*
Hand Dominance

RightLeftAmbedextrous
Vital Signs
Memory
Attention
Verbal Cues
Judgement
Behavior
Insight
Precautions
Sensory

Functional Outcome Measures
Barthel ADL Index

Test Performed
Barthel ADL Index Results
Timed Up and Go

Test Performed
Time of over 18 seconds indicates increased risk for fall.
Timed Up and Go Results
Five Times STS

Test Performed
Five Times STS Results
DASH Test

Test Performed
DASH Test Results
Modified Berg Bal

Test Performed
1- Standing unsupported with eyes closed. Instructions: “Close your eyes and stand still for 10 seconds”
2- Stand unsupported with feet together. Instructions: “Place your feet together and stand without holding on to anything”
3- Reaching forward with outstretched arm. Instructions: “Lift you arm to 90 degrees. Stretch out your fingers and reach forward as far as you can” (Examiner places a ruler and end of fingertips when arm is at 90 degrees. Fingers should not touch the ruler while reaching forward. The recorded measure is the distance toward that the fingers reach while the person is in the most forward lean position.)
4- Pick up object from the floor from a standing position. Instructions: “Please pick up the shoe/slipper that is placed in front of your feet”
5- Turn to look behind over left and right shoulders while standing. Instructions: “Turn you upper body to look directly over your left shoulder. Now try turning to look over you right shoulder”
6- Turn 360. Instructions: “Turn completely in a full circle. Pause, then turn in a full circle in the other direction”
7- Place alternate foot on bench or stool while standing unsupported. Instructions: “Place each foot alternately on the bench (or stool). Continue until each foot has touched the bench (or stool) four times”. (Recommended use of 6- inch-high-bench.)
8- Stand unsupported with one foot in front. Instructions: “Place one foot directly in front of the other. If you feel that you can’t place your foot directly in front, try to step far enough ahead that the heel of your forward foot is ahead of the toes of the other foot” (Demonstrate this test item)
9- Standing on one leg. Instructions: “Please stand on one leg as long as you can without holding onto anything”
Modified Berg Results
Functional Reach Test

Test Performend
Functional Reach Results
Arm Curl Test

Test Performed
Arm Curl Results
Patient Specific Functional Scale

Test Performed
Patient Specific Functional Scale

Clinical Functional Assesment

	N/A	0%	10%	20%	30%	40%	50%	60%	70%	80%	90%	100%
Transfers sit to stand
Sit to stand w/out arms
Toileting w/ arm frame
Toileting w/out arms
Upper body dressing
LB dressing pants
LB dressing foot
Supine/sit
Reposition in bed
Rolling
Grooming standing
Grooming seated
Feeding
Feeding setup
Bathing standing
Bathing seated
Carrying ADL objects
Kitchen access
Closet access
Making bed

Total % of Functional Complexity / Does not include areas marked as N/A or 0%
Calculator

	N/A	0%	10%	20%	30%	40%	50%	60%	70%	80%	90%	100%
Wheelchair mobility
Ambulation in Apt.
Access in community
Light housekeeping
Stair Climbing

	Functional Progress Achieved
Dressing UB
Dressing LB
Toileting
Transfers
Grooming
Bed Mobility
Bathing
Carrying Objects
Closet Access
Kitchen Access
Making Bed
Light Cleaning
Feeding
Wheelchair mobility

Functional Reporting
Current
Modifier
Goal
Modifier
Discharge
Modifier
PQRS

To trigger Fall Risk Plan Of Care the patient must have 2 falls or 1 fall w/ injury in previous year. Assesment must include gate/balance/vision/home fall hazards.

Functional Goals

	Short Term Goals	Long Term Goals
Dressing UB
Dressing LB
Toileting
Transfers
Grooming
Bed Mobility
Bathing
Carrying Objects
Closet Access
Kitchen Access
Making Bed
Light Cleaning
Feeding
Wheelchair mobility

FINAL / SUBMIT
Recommended Plan
Therapist Name
Therapist Email*
Date

MonthDayYear
Sign w/ Initials
Should be Empty:

I can't walk very well
My legs feel weak
I feel weak
I feel dizzy
I have trouble getting up from the chair.
Sometimes I feel like I lose my balance
I feel like I'm going to fall
Reports pain in knees
Reports pain in foot
Reports pain in hip
Reports pain in back
I have no energy
I feel tired
I don't get tired as easily
I feel my balance is improving
I feel more confident
I feel I'm getting stronger
I feel my legs are getting stronger
I still have pain but can move better
My pain is less
I can get around the bathroom more easily
I can manage better in the kitchen
I can get in and out of closet more easily
I can get in and out of bed easier
I need less help getting dressed
I feel safer walking
I need less help in the shower
I need less help in the bathroom

Lifelong Therapeutics / Occupational Therapy