Reason for Referral
Activities
Impairments
Assessment and goals
Plan of care
100
Pills and supplements with dosage and frequency
What are medications?
100
How a patient walks
What is gait/ambulation?
100
Heart rate, respiration rate, blood pressure
What are vital signs?
100
The therapist's best estimate of the outcome of therapy
What is a patient goal
100
Road map that outlines the patient's therapy program
What is Plan of Care?
200
Leisure and community activities
What is social history?
200
Every day activities that require instruments or equipment to accomplish
What are IADL's?
200
Strength, dynamometry, isokinetic testing
What are muscle performance measures?
200
"The patient will return to work in 2 weeks with no restrictions" is an example of this type of goal.
What is a participation goal?
200
Ultrasound, hydrotherapy, laser
What are three modalities or procedural interventions?
300
Information about the problem that brings the patient to therapy.
What is current condition?
300
basic skills that all patients must be able to do every day.
What are ADLs?
300
Measures of joint angles
What is ROM or goniometry?
300
"The patient will be able to walk on uneven surfaces using crutches in the correct gait pattern in one week" is an example of this type of goal.
What is an activity goal?
300
teaching a patient about his/her condition
What is patient related education?
400
Other problems that impact the current condition
What is past medical history?
400
Details on specific tasks that the patient does at work
What are work activities or job tasks?
400
description of the way a patient stands and sits
What is posture?
400
Skilled service and medical necessity
What are two requirements for reimbursement from Medicare?
400
Arranging the patient's therapy schedule with other healthcare providers
What is coordination/communication?
500
The patient's ideas about the outcome of therapy
What are patient goals?
500
Ability to get from the supine position to edge of bed sitting.
What is bed mobility?
500
Visual analog scale, drawing, number scale
What are ways to describe pain?
500
How therapy will help the patient improve his/her quality of life
What is the benefit statement in the assessment?
500
Signature, date and license number
What is authentication?
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