OT OASIS C FOLLOW-UP/RECERT - TriPoint Healthcare

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Patient Name_____________________________________________Date:_____/_____/_____ 4 4-Intermittent confusion B. History of Falls (past 3 months) B. Score _____ 0-No falls ( in past 3 months) 2-1-2 falls (in past 3 months) 4-3 or more falls (in past 3 months C. Ambulation/Elimination Status C. Score _____ 0-Ambulatory/continent 2- Chair bound 4-Ambulatory/incontinent D. Vision Status D. Score: _____ 0-Adequate (with or without glasses) 2-Poor (with or without glasses) 4-Legally blind E. Gait/Balance: to assess the gait/balance, have patient stand on both feet without E. Score: _____ holding onto anything: walk straight forward; walk through a doorway; and make a turn. 0-Gait/balance normal 1-Balance problem while standing 1-Balance problem while walking 1-Decreased muscular coordination 1-Change in gait pattern when walking through doorway 1-Jerking or unstable when making turns 1-Requires use of assistive device (cane, w/c, furniture..) F. Orthostatic Changes F. Score: _____ 0-No noted drop in blood pressure between lying and standing. No change in cardiac rhythm. 2-Drop 20. G. Medications: Respond below based on the following types of medications: G. Score: _____ anesthetics, antihistamines, antihypertensives, antiseizure, benzodiazepines, cathartics, diuretics, hypoglycemics, narcotics, phychotropics, sedatives/hypnotics. 0-None of these medications taken currently on w/in last 7 days 2-Takes 1-2 of these medications currently and/or w/in last 7 days 4-Takes 3-4 of these medications currently and/or w/in 7 days 1-If patient has had a change in medication and/or change in dosage in past 5 days, score + 1 additional point. H. Medications: Respond below based on the following predisposing conditions: H. Score: ______ hypotension, vertigo, CVA, Parkinson’s disease, loss, of limb(s), seizures, arthritis, osteoporosis, fractures. 0-None present 2-1-2 present 4-3 or more present T<strong>OT</strong>AL SCORE: (score of 10 represents High Risk) ______ Patient informed about the safety/falls prevention recommendations listed in the admission packet ____________
Patient Name_____________________________________________Date:_____/_____/_____ 5 M1200-Vision (with corrective lenses if the patient usually wears them): 0-Normal vision: sees adequately in most situations; can see medication labels, newsprint 1-Partially impaired: cannot see medication labels or newsprint, but can see obstacles in path, and the surrounding layout; can count fingers at arm’s length 2-Severely impaired: cannot locate objects without hearing or touching them or patient nonresponsive M1242-Frequency of Pain: Interfering with patient’s activity or movement: 0-Patient has no pain or pain does not interfere with activity or movement 1-Patient has pain that does not interfere with activity or movement 2-Less often than daily 3-Daily, but not constantly 4-All of the time Location: Abdomen Arm Back Chest Generalized Head/Neck Leg Shoulder Other Patient Describes Pain as: Ache Burning Dull Sharp Stabbing Throbbing Pain Intensity Level Now: 0 01 02 03 04 05 06 07 08 09 10 Pain Intensity at Worst: 0 01 02 03 04 05 06 07 08 09 10 Pain Intensity at Best: 0 01 02 03 04 05 06 07 08 09 10 Acceptable Level of Pain: 0 01 02 03 04 05 06 07 08 09 10 Pain Quality: Bone Nerve Somatic Visceral Other Other Onset: _______________________________________________________________ Frequency: ___________________________________________________________ Duration: Constant Intermittent Occasional With Movement Note: Barriers to Pain Control Culture Education Philosophy of caregiver Physical Emotional Spiritual Financial Other
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OT OASIS C FOLLOW-UP/RECERT - TriPoint Healthcare

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