OT OASIS C FOLLOW-UP/RECERT - TriPoint Healthcare

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Patient Name_____________________________________________Date:_____/_____/_____ 14 Right Right ______ ______ _______ Pronation Left Left ______ ______ _______ Right Right ______ ______ _______ Wrist Flexion Left Left ______ ______ _______ Right Right ______ ______ _______ Extension Left Left ______ ______ _______ Right Right ______ ______ _______ Ulnar Deviation Left Left ______ ______ _______ Right Right ______ ______ _______ Radical Deviation Left Left ______ ______ _______ Right Right ______ ______ _______ Thumbs MP Flexion Left Left ______ ______ _______ Right Right ______ ______ _______ IP Extension Left Left ______ ______ _______ Right Right ______ ______ _______ Abduction Left Left ______ ______ _______ Right Right ______ ______ _______ Extension Left Left ______ ______ _______ Right Right ______ ______ ________ Opposition Left Left ______ ______ ________ Right Right ______ ______ ________ Left Fingers Right Index Middle Ring Little Little Ring Middle Index MP Flex PIP Flex DIP Flex Abd Tip-DPC Functional Hand Strength Trial #1 Trial #2 Trial #3 Trial #1 Trial #2 Trial #3 Grip Tip Pinch Lateral Pinch
Patient Name_____________________________________________Date:_____/_____/_____ 15 3 Jaw Chuck Patient CG/Other Status Comments ADL ____________________________________________ Techniques ____________________________________________ Energy ____________________________________________ Conservation ____________________________________________ HEP ____________________________________________ ____________________________________________ Safety ____________________________________________ Measures ____________________________________________ Community ____________________________________________ Resources ____________________________________________ Use of ____________________________________________ Adaptive Equipment _____________________________________________ Other _______________________________________ _______________________________________ M2200-Therapy Need: In the home health plan of care for the Medicare payment episode for which this assessment will define a case mix group, what is the indicated need for therapy visits (total of reasonable and necessary physical, occupational, and speech-language pathology visits combined) (Enter zero “000" if no therapy visits indicated.) Number of therapy visits indicated (total of physical, occupational and speech-language pathology combined). NA-Not applicable: No case mix group defined by this assessment. Homebound Limitations: Bed Bound Chair bound Medically restricted to home Other Unable to ambulate Unable to ambulate None more than 10ft more than 20ft Requires Assistance: Frequent rest periods Ambulance to leave home Assist of 1 person to ambulate/transfer Assist of 2 people to Mechanical device for transfer Requires assistance due to mental confusion None ambulate/transfer Patient requires following assistive device(s) Cane Pronged Walker Walker Wheeled walker Wheelchair Crutches Specialized Orthotics Prosthesis Oxygen
Page 1 and 2: WEST PENN ALLEGHENY HOME CARE FOLLO
Page 3 and 4: Patient Name_______________________
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OT OASIS C FOLLOW-UP/RECERT - TriPoint Healthcare

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