OT OASIS C FOLLOW-UP/RECERT - TriPoint Healthcare
OT OASIS C FOLLOW-UP/RECERT - TriPoint Healthcare
OT OASIS C FOLLOW-UP/RECERT - TriPoint Healthcare
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Patient Name_____________________________________________Date:_____/_____/_____<br />
15<br />
<br />
3 Jaw Chuck <br />
<br />
Patient<br />
CG/Other Status Comments<br />
ADL ____________________________________________<br />
Techniques ____________________________________________<br />
Energy ____________________________________________<br />
Conservation ____________________________________________<br />
HEP ____________________________________________<br />
<br />
____________________________________________<br />
Safety ____________________________________________<br />
Measures ____________________________________________<br />
Community ____________________________________________<br />
Resources ____________________________________________<br />
Use of ____________________________________________<br />
Adaptive<br />
Equipment _____________________________________________<br />
Other _______________________________________<br />
<br />
_______________________________________<br />
M2200-Therapy Need: In the home health plan of care for the Medicare payment episode for which this assessment will define a<br />
case mix group, what is the indicated need for therapy visits (total of reasonable and necessary physical, occupational, and<br />
speech-language pathology visits combined) (Enter zero “000" if no therapy visits indicated.)<br />
Number of therapy visits indicated (total of physical, occupational and speech-language<br />
pathology combined).<br />
<br />
NA-Not applicable: No case mix group defined by this assessment.<br />
Homebound Limitations:<br />
Bed Bound Chair bound Medically restricted to home Other<br />
Unable to ambulate Unable to ambulate None<br />
more than 10ft<br />
more than 20ft<br />
Requires Assistance:<br />
Frequent rest periods Ambulance to leave home Assist of 1 person to ambulate/transfer<br />
Assist of 2 people to Mechanical device for transfer Requires assistance due to mental confusion None<br />
ambulate/transfer<br />
Patient requires following assistive device(s)<br />
Cane Pronged Walker Walker<br />
Wheeled walker Wheelchair Crutches<br />
Specialized Orthotics Prosthesis Oxygen