Cleveland Clinic - OT Assessment OASIS.pdf - TriPoint Healthcare

CLEVELAND CLINIC HOME CAREOCCUPATIONAL THERAPY ASSESSMENTPATIENT NAME: __________________________________________________ DATE: ______________ THERAPIST INITIALS: _________PATIENT / CAREGIVER OUTCOMES MET NOT MET IF NECESSARY, EXPLAIN1. Verbalizes adverse S/Sx to report2. Verbalizes correct medication schedule3. Verbalizes how and when to call for help4. Verbalizes measures to ensure personal safety5. Demonstrates safe use of equipment6. Verbalizes primary concern and personal goals7. Agrees with plan of care/projected length of serviceCLINICAL NOTE / NARRATIVEORDERS AND GOALS FOR PLAN OF TREATMENT 485OT FREQUENCYHCA FREQUENCYNumber ofVisitsPeriod(day, week, month)Duration(# of periods)# of PRNVisitsPRNReasonStart DateNumber ofVisitsPeriod(day, week, month)Duration(# of periods)Start DateS:Forms/OT Assessment OASIS C 1209.doc Page 1 of 9 12/21/09

CLEVELAND CLINIC HOME CAREOCCUPATIONAL THERAPY ASSESSMENTPATIENT NAME: __________________________________________________ DATE: ______________ THERAPIST INITIALS: _________PHYSCIAN ORDERED ADDITIONAL SERVICES I25A Aide for personal care assistance beginning week of (specify):_________________________________________________________ I20 SN Evaluation (specify):_______________________________________________________________________________________ I21 MNT Evaluation (specify):______________________________________________________________________________________ I22 ST Evaluation (specify):________________________________________________________________________________________ I23 MSW Evaluation (specify):______________________________________________________________________________________ I24 OT Evaluation (specify):_______________________________________________________________________________________ I24A Behavioral Health Consult (specify):______________________________________________________________________________ I27 Home Care Aide supervisory visit at least every 14 days ______________________________________________________________ I28 Patient refused the following physician ordered services (specify) ______________________________________________________Clinical DefinitionsCODE AD1 Description: #Universal Advance Directives Modifier Start Date End DateInterventionsCode DescriptionA01 Specific content of Advance DirectivesA01A Withhold/Withdraw artificial nutritionA01B Withhold/Withdraw artificial hydrationA01C Specific wishes as written on actual Advance Directive formA04 Specified Other: (patient verbal wishes)A05 Organ donorCODE N20 Description: #Universal Braden Scale Protocol Modifier Start Date End DateGoalsCode DescriptionOLTG *Patient’s Skin integrity will be intactGO1 Verbalizes the risks and prevention of skin breakdownsCODE N20 Description: #Universal Braden Scale Protocol Modifier Start Date End DateInterventionsCode DescriptionA LOW (15-16 if under 75 years old OR 15-18 if over 75 years old)A01A Instruct on skin integrity and inspection of bony prominencesA01B Instruct on routine skin careA01C Instruct on importance of activityA01D Instruct on elevation and protection of heelsA01E Instruct on incontinence careS:Forms/OT Assessment OASIS C 1209.doc Page 2 of 9 12/21/09

CLEVELAND CLINIC HOME CAREOCCUPATIONAL THERAPY ASSESSMENTPATIENT NAME: __________________________________________________ DATE: ______________ THERAPIST INITIALS: _________CODE N20 Description: #Universal Braden Scale Protocol Modifier Start Date End DateInterventionsCode DescriptionA01P Evaluate need for pressure reduction surfaces for bed or wheelchairA01R Consider WOCN consult (go to referrals and consults)A01Z +B MODERATE (Total score 13-14)B02A Instruct on skin integrity and inspection of bony prominencesB02B Instruct on routine skin careB02C Instruct on importance of activityB02D Instruct on heel elevation and protectionB02E Instruct on incontinence careB02F Instruct on risk of friction and shear and preventionB02G Instruct on importance of position changes every 1 to 2 hoursB02P Evaluate need for pressure reduction surfaces for bed or wheelchairB02R Consider WOCN consult (go to referrals and consults)B02S Consider MNT/PT/OT eval (go to referrals and consults)B02Z +C HIGH (Total score less than or equal to 12)C03A Instruct on skin integrity and inspection of bony prominencesC03B Instruct on routine skin careC03C Instruct on importance of activityC03D Instruct on heel elevation and protectionC03E Instruct on incontinence careC03F Instruct on risk of friction and shear and preventionC03G Instruct on importance of position changes every 1 to 2 hoursC03P Evaluate need for pressure reduction surfaces for bed or wheelchairC03R WOCN consult (must be ordered - go to referrals and consults)C03S MNT consult (must be ordered - go to referrals and consults)C03T Consider PT/OT eval (go to referrals and consults)C03Z +CODE DC1 Description: #Universal Discharge Problems Modifier Start Date End DateGoalsCode Description*Verbalizes understanding of the ongoing plans for discharge from Home Care ServicesG01G01A Discharge NOT anticipated due to: (specify)G02 *Verbalizes understanding of provided discharge instructionsG03 Independent with ordering needed suppliesG04 Verbalizes the name and telephone number of the DME companyG05 Arrangements completed for outpatient servicesG06 Arrangements completed for community servicesS:Forms/OT Assessment OASIS C 1209.doc Page 3 of 9 12/21/09

CLEVELAND CLINIC HOME CAREOCCUPATIONAL THERAPY ASSESSMENTPATIENT NAME: __________________________________________________ DATE: ______________ THERAPIST INITIALS: _________CODE DC1 Description: #Universal Discharge Problems Modifier Start Date End DateGoalsCode DescriptionG10 Medicare beneficiary will have at least 2 days advance notice of non-covered services and willunderstand his or her right to appealInterventionsCode Description Modifier Start Date End DateI02 *Provide written discharge instructions.I03 Patient being discharged prior to the end of projected visits due to:I04 Instruct on how to obtain supplies.I06 Provide name and telephone number of DME companyI06A Provide name and telephone number of DME companyI06B Provide name and telephone number of DME companyI08 Instruct on completed outpatient arrangements, contact name and telephone numberI08A Instruct on completed outpatient arrangements, contact name and telephone numberI08B Instruct on completed outpatient arrangements, contact name and telephone numberI10 Instruct on newly involved community services/resources, contact name, and numberI10A Instruct on newly involved community services/resources, contact name, and numberI10B Instruct on newly involved community services/resources, contact name, and numberI12 Delivery (NOMNC) Notice of Medicare Non-Coverage to beneficiary for Non-Coveragedate of:CODE N39 Description: #Universal Falls Risk Prevention – Missouri Modifier Start Date End DateGoalsCode DescriptionG01 *Will verbalize/demonstrate knowledge of fall prevention measuresCODE N39 Description: #Universal Falls Risk Prevention – Missouri Modifier Start Date End DateInterventionsCode DescriptionI01 *Instruct on Fall Prevention Guidelines in admission handbook.I03 Instruct on environmental hazardsI05 Recommend need for additional equipmentI07 +I09 -CODE N117 Description: Diabetes Modifier Start Date End DateGoalsCode DescriptionOLTG Verbalizes understanding and compliance with all aspects of diabetes self managementGO1 Verbalizes understanding if diabetes disease processGO2 Verbalizes long term effects of diseaseGO3 Demonstrates effective diabetes managementS:Forms/OT Assessment OASIS C 1209.doc Page 4 of 9 12/21/09

CLEVELAND CLINIC HOME CAREOCCUPATIONAL THERAPY ASSESSMENTPATIENT NAME: __________________________________________________ DATE: ______________ THERAPIST INITIALS: _________CODE N117 Description: Diabetes Modifier Start Date End DateInterventionsCode DescriptionA00 *Diabetes education documented in assessmentA04 Blood glucose monitoring: (specify frequency)A05 Nurse may conduct finger stick blood sugars (reference range for a normal blood glucose will be90-130mg/dl unless physician ordered patient specific parameters)A05A Report abnormal blood sugar results to physician. (specify low and high values)A06 Patient self reported blood glucose results may be reported to the physcianA07 +A11 Instruct on insulin management and storage of suppliesA12 Instruct on signs and symptoms of hypo and hyper glycemia and managementA13 Instruct on diabetes home testing and recording results.A14 Instruct on nutrition basicsA21 Instruct on sick day management.A22 *Instruct on monitoring skin of the lower extremities and foot careA23 Consider MNT referral, MANDATORY FOR ALL NEW DIABETICS (go to referral and consults)A24 Consider DE referral, MANDATORY FOR ALL NEW DIABETICS (go to referral and consults)I01 Instruct on diabetes disease process.I09 -CODE A007 Description: Home Health Aide PDA Modifier Start Date End DateGoalsCode DescriptionG01 Patient will maintain adequate hygiene.G02 Patient will demonstrate safe ambulation, transfers, positioning.G03 Patient will verbalize optimal comfort.InterventionsCode Description Modifier Start Date End DateI0A To be ResuscitatedI0B DNR Comfort Care ArrestI0C DNR Comfort CareI0D Patient on the following precautionsI0DA Standard PrecautionsI0E Take temperature, call case manager if temp is greater than (specify)I0F Weigh patient: call case manager if wt. gain/loss of (specify)I0G Shower with benchI0GA Shower without benchI0GB Shower with hand held shower unitI0GC Tub BathI0GD Sponge bath in bedS:Forms/OT Assessment OASIS C 1209.doc Page 5 of 9 12/21/09

CLEVELAND CLINIC HOME CAREOCCUPATIONAL THERAPY ASSESSMENTPATIENT NAME: __________________________________________________ DATE: ______________ THERAPIST INITIALS: _________CODE A007 Description: Home Health Aide PDA Modifier Start Date End DateInterventionsCode DescriptionI0GE Sponge bath in chair/commodeI0GF Oral careI0GG Hair careI0GH Nail care (clean/file)I0GI Skin care (specify)I0GJ Shave (electric or razor)I0GK Assist with dressing/undressingI0GL Apply support stockingsI0H Assist with use of bedpan/urinalI0HA Catheter care (specify)I0HB Apply/change condom catheterI0HC Empty urinary drainage/ostomy bagI0HD Record urinary outputI0HE Record bowel movements chart date and appearanceI0HF Notify case manager if no BM for (specify) daysI0HG Feeding tube care: wash with soap and waterI0I Diet:I01A Food allergies/sensitivitiesI01B Simple meal prepI01C Make bedI01D Change bed linen as indicated and prnI01E Laundry: only one load wash or dry of patient’s laundryI01F Light housekeeping of area used by patient and HCAI0J Turn and positionI0JA Assist with transfer (chari/wheelchair/bedside commode)I0JB Assist with transfer (hoyer lift/transfer board/pivot/lift)I0JC Assist with ambulation (independent/with supervision/with contact guard)I0JD Assist with ambulation with device or prosthesis (specify)I0JE Partial weight bearing (specify Rt or Lt)I0JF Non weight bearing (specify Rt or Lt)I0JG Assist/perform ROM exercises per therapy instructions (specify)I0K Notify case manager of the following:I0L Notify case manager if patient change in orientationI0M *I0N *Code OT01 Description : Occupational Therapy Modifier Start Date End DateGoalsCode DescriptionDC1 Discharge when goals met and patient able to manage safely with maximum independenceS:Forms/OT Assessment OASIS C 1209.doc Page 6 of 9 12/21/09

CLEVELAND CLINIC HOME CAREOCCUPATIONAL THERAPY ASSESSMENTPATIENT NAME: __________________________________________________ DATE: ______________ THERAPIST INITIALS: _________Code OT01 Description : Occupational Therapy Modifier Start Date End DateGoalsCode DescriptionDC2 Discharge to care of family supports when goals are metDC3 Discharge to outpatient program when goals are met or no longer homeboundDC4 Evaluation visit only discharge this visitDC5 *DCP Return to educational settingG00 OCCUPATIONAL THERAPY GOALS, REHABILITATION PROTENTIAL AND DISCHARGE PLANG01 Patient or caregiver will demonstrate compliance with and participation in the plan of treatmentwhile maximizing home safety with improved tolerance for activity and use of appropriateequipment if necessaryG02 Patient demonstrates improved self bathingG03 Patient demonstrates improved self feedingG04 Patient demonstrates improved self dressingG05 Patient demonstrates improved self groomingG06 Patient demonstrates improved self toiletingG07 Patient demonstrates the ability to safely prepare mealsG08 Patient demonstrates safe kitchen mobilityG09 Patient demonstrates the ability to safely clean their homeG10 Patient demonstrates the ability to safely complete laundry tasksG11 Patient demonstrates the ability to safely manage moneyG12 Patient demonstrates improved functional transfersG13 Patient demonstrates improved strength to meet individual functional goalsG14G15Patient demonstrates improved balance for ADL activitiesPatient demonstrates improved coordinationG16G17Patient demonstrates improved ROMPatient demonstrates improved cognitive or perceptual motor skillsG18 Patient will report an acceptable level of pain and will verbalize/demonstrate measures to controlpainG19 Patient demonstrates improved sensation or adherence to compensatory techniquesG20 Patient demonstrates the ability to position self for safety and comfortG21 Caregiver will demonstrate ability to safely assist patient with appropriate functional activitiesG22 Patient/caregiver understands edema management strategiesG23 Patient/caregiver demonstrates the ability to manage functional limitations through assistive orenergy saving devicesG23A Patient/caregiver will verbalize/demonstrate knowledge of fall prevention measuresG24 +G25 *GP1 Patient demonstrates ability to prepare a snackGP2 Patient demonstrates ability to perform choresGP3 Patient demonstrates ability to return to school skillsS:Forms/OT Assessment OASIS C 1209.doc Page 7 of 9 12/21/09

CLEVELAND CLINIC HOME CAREOCCUPATIONAL THERAPY ASSESSMENTPATIENT NAME: __________________________________________________ DATE: ______________ THERAPIST INITIALS: _________Code OT01 Description : Occupational Therapy Modifier Start Date End DateGoalsCode DescriptionGP4 Patient demonstrates functional playGP5 Patient demonstrates improved motor controlGP6 Patient will demonstrate progression with developmental sequencing:GP7 Patient will demonstrate normalization of reflexes and reactionsGP8 Patient will demonstrate improved fine motor coordinationGP9 Patient will demonstrate improved fine motor coordinationPN *Notification to physician that a copy of the discharge summary is available upon requestRP1 Good for patient or caregiver to accomplish goalsRP2 Fair for patient or caregiver to accomplish goalsRP3 Poor for patient or caregiver to accomplish goalsRP4 *InterventionsCode Description Modifier Start Date End Date140 Instruct patient/caregiver on pharmacological and non pharmacological measures to control painA01 OT evaluation and treatment for maximum patient comfort and improved self care. Assist orinstruct patient or caregiver in maximizing functional ability and maintaining home safetyA01A Implement a falls prevention program per organization protocol.A02 Assess need for splintingA04 Assess level of pain and patient’s current knowledge of measures to control painA10 Assess degree of edema and patient’s current knowledge of strategies to reduce edemaA11 +A12 Self care trainingA13 Home management trainingA14 Functional transfer trainingA15 Therapeutic Exercise instructionsA16 Balance trainingA17 SplintingA18 Adaptive equipment assessment and instructionA19 Sensory treatmentA20 Cognitive or perceptual trainingA21 Assist or instruct patient/caregiver in maximizing functional ability and maintaining home safety.A22 Neuro-developmental TherapyA23 Fine motor co-ordination trainingInterventionsCode Description Modifier Start Date End DateA30 NUTRITIONAL RISK ACTIONS INITIATEDA30A Reassess in 50 daysS:Forms/OT Assessment OASIS C 1209.doc Page 8 of 9 12/21/09

CLEVELAND CLINIC HOME CAREOCCUPATIONAL THERAPY ASSESSMENTPATIENT NAME: __________________________________________________ DATE: ______________ THERAPIST INITIALS: _________Code OT01 Description : Occupational Therapy Modifier Start Date End DateInterventionsCode DescriptionA30B One day diet diary/log to be collectedA30C Other actions initiated:A30D Patient/family refuses the following:A30E Patient/family refuses MNT interventions.I18 Educate patient/caregiver on MNT dietary recommendations.I29 Implement a falls prevention program (e.g., for example remove throw rugs, teach safe use ofassist/safety devices).I30 Instruct patient/caregiver on energy conservation and work simplification methodsI35 Instruct caregiver in safe methods to assist patientI45 Instruct patient/caregiver on edema reducing strategiesI51 *Verbal orders for plan of care received from Dr. ______________________________________________________________________________________________________________for certification period from ___________________________________ through__________________________________ received on ____________________________________.Date Date Date______________________________________________________________________________________________ _______________________Therapist Signature and Printed Name DateTime In: AMPMTime Out: AMPMFOR OFFICE USE ONLY_____________________________________________________________________________________ ________________________Verbal Order entered by DateS:Forms/OT Assessment OASIS C 1209.doc Page 9 of 9 12/21/09