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 />
16<br />
Slideboard None Other<br />
Note:<br />
With activity of leaving home the patient may experience:<br />
Dizziness/vertigo Angina/chest pain Pain<br />
Swelling Respiratory distress/ Unsteady gait/Frequent falls/<br />
dyspnea/SOB<br />
Mental confusion<br />
Serious risk of infection Incontinence of urine<br />
Incontinence of stool None Other<br />
poor balance<br />
Homebound status is primarily due to:<br />
Infected/Drainage/Large/Painful wound Profound generalized weakness Morbid obesity<br />
Orthopedic condition Cardiac condition Neurologic condition<br />
Lung condition Immunosupression Psychological impairment<br />
Peripheral vascular disease Urinary condition Bowel condition<br />
None<br />
Other<br />
Note:<br />
CHHA Name<br />
______________________________________________________________________________<br />
Agency<br />
________________________________________________________________________________________________<br />
Schedule<br />
Orientation to Care<br />
Care Plan Instruction Given<br />
Services Supervised<br />
Services Evaluated<br />
_______/_______/_______Next Scheduled Supervisory Visit<br />
Review of Vulnerabilities:<br />
None Noted Cognition Impairment Substance Abuse