OT OASIS C FOLLOW-UP/RECERT - TriPoint Healthcare

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Patient Name_____________________________________________Date:_____/_____/_____ 16 Slideboard None Other Note: With activity of leaving home the patient may experience: Dizziness/vertigo Angina/chest pain Pain Swelling Respiratory distress/ Unsteady gait/Frequent falls/ dyspnea/SOB Mental confusion Serious risk of infection Incontinence of urine Incontinence of stool None Other poor balance Homebound status is primarily due to: Infected/Drainage/Large/Painful wound Profound generalized weakness Morbid obesity Orthopedic condition Cardiac condition Neurologic condition Lung condition Immunosupression Psychological impairment Peripheral vascular disease Urinary condition Bowel condition None Other Note: CHHA Name ______________________________________________________________________________ Agency ________________________________________________________________________________________________ Schedule Orientation to Care Care Plan Instruction Given Services Supervised Services Evaluated _______/_______/_______Next Scheduled Supervisory Visit Review of Vulnerabilities: None Noted Cognition Impairment Substance Abuse
Patient Name_____________________________________________Date:_____/_____/_____ 17 Sensory Deficit Impaired Mobility Functional Limitations Environmental Concerns Dependent upon Caregiver Other: Rehab Potential: _____________________________ To Achieve Goals by Next Visit Date _______/_______/_______ _______/_______/_______ Plan: Phone Call Made to: ________________________________________ Details: ____________________________________________________________________________________________ ____ Visit Narrative: To use this form: 1) Select an Active Problem. Based upon this selection, 2) select Active Goals & Interventions 3) Check “Add Selected G/I” to populate the G/I Addressed This visit text box 4) Return to the Active Problem, select new Problem 5) Select new G/I 6) Re-check the “Add Selected” box Active Problems Active Goals: Add Selected Goals
Page 1 and 2: WEST PENN ALLEGHENY HOME CARE FOLLO
Page 3 and 4: Patient Name_______________________
Page 15: Patient Name_______________________

OT OASIS C FOLLOW-UP/RECERT - TriPoint Healthcare

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