Q5001: Hospice or Home Health Care

PHYSICAL THERAPY
provided in patients home/residence
Q5002: Hospice or Home Health Care
EVALUATION
Initial Evaluation provided in Assisted Living Facility DATE OF SERVICE ______ /______ /______
Q5009: Hospice or Home Health Care
Re-Evaluation (Type)__________________________ provided in place not otherwise specified TIME IN__________ TIME OUT__________
HOMEBOUND REASON: Needs assistance for all activities Residual weakness SOC DATE_____ /_____ /_____
Requires assistance to ambulate Confusion, unable to go out of home alone G0151 G0159 Maintenance
Unable to safely leave home unassisted Severe SOB, SOB upon exertion
PERTINENT BACKGROUND INFORMATION
Dependent upon adaptive device(s) Medical restrictions
Other (specify)__________________________________________________________________ Prior Level of Functioning:
ADLs: Independent Needed assist
PERTINENT MEDICAL INFORMATION Total assist
Onset Date:_____ /_____ /_____ In Home Mobility: Independent Assistive device
Primary Diagnosis: ________________________________________________________________ Wheelchair / scooter Non-ambulatory
Medical Precautions/Limitations: Community Mobility: Independent
Hypertension Cardiac Diabetes Respiratory Osteoporosis Assistive device Wheelchair / scooter
Fractures Cancer Infection Immunosuppressed Open Wound Non-ambulatory

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Other: ____________________________________________________________________________ History of Falls:

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Y/ N If yes, date of last fall:_____ /_____ /_____

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PAIN Intervention in place? Yes No

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Rating scale: 0 1 2 3 4 5 6 7 8 9 10 Current pain level:______ If yes, specify: ________________________________

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No pain Mod pain Worst pain (subjective reporting)
Reported by: Patient Family Caregiver

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Best pain gets:________ Worst pain gets:________ Acceptable level:________
Living Arrangements / Support System:

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Pain quality:__________________ Pain location: ________________________________________ Lives alone Caregiver available

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(ache, sharp, dull, etc.)
Limited support No caregiver available
Frequency: Occasionally Continuous Intermittent

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Comment: _______________________________________

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What makes pain worse? Movement Ambulation Immobility
Environmental Barriers: Clutter Throw rugs

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Other: __________________________________________________________________________

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Referral needed? Yes No Referred to:____________________________________________
Adaptive equipment needed: Yes No
(specify) _______________________________________

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Impacting function? Yes No (specify) _____________________________________________ ______________________________________________

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POC Goal Needed? Yes No Other: ___________________________________________
VITAL SIGNS
Blood Pressure: Sitting/lying R_____________ L _____________
4 3
BEHAVIOR/MENTAL STATUS
Alert Oriented Cooperative Confused

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Standing R_____________ L _____________ Memory deficits: Short term Long term Impaired judgment
Temperature:_________ Oral Axillary Other: _________________
Pulse: Apical_________ Brachial_________ Radial_________

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Other: __________________________________________________________
________________________________________________________________

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Rhythm: Regular Irregular

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________________________________________________________________
Respirations:_________ Regular Irregular Impacting function? Yes No (specify) ___________________________
O2 @ ______LPM via: Cannula Mask Trach
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__________________________________________________________________
O2 saturation _____%: At rest With activity POC Goal Needed? Yes No

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Impacting function? Yes No (specify) ___________________________
__________________________________________________________________
POC Goal Needed? Yes No
GAIT
Assistance: Independent SBA CGA Min. assist Mod. assist Max. assist Dependent
Adaptive Device: No device Crutches FWW 4WW Hemi Walker SBQC LBQC SPC Other: _____________________
Surfaces within Functional Area: Level Uneven Stairs (# if known______) Distance/Time:___________/__________
Functional Distance Needed for: Toileting: ______ ft Bed: ______ ft Chair: ______ ft
Weight Bearing Status: FWB WBAT PWB TDWB NWB
Gait Quality/Deviations/Postures: _____________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Impacting function? Yes No (specify) ________________________________________________________________________________________________
__________________________________________________________________________________________________ POC Goal Needed? Yes No
Comments: ________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

PATIENT NAME Last, First, Middle Initial ID#

Form 3507P-11 Rev. 4/13 BRIGGS, Des Moines, IA (800) 247-2343

Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A. PHYSICAL THERAPY EVALUATION
 PHYSICAL THERAPY EVALUATION (Contd.)
MUSCLE STRENGTH/FUNCTIONAL ROM EVAL FUNCTIONAL INDEPENDENCE/BALANCE EVAL
STRENGTH ROM TASKS ASSIST SCORE ASSISTIVE DEVICES/COMMENTS

BED MOBILITY
AREA ACTION
Right Left Right Left Roll/Turn

Shoulder Flex/Extend Sit/Supine

Abd./Add. Scoot/Bridge
UPPER EXTREM.

Int. Rot./Ext. Rot. Sit/Stand

TRANSFERS
Elbow Flex/Extend Bed/Wheelchair

Forearm Sup./Pron. Toilet

Wrist Flex/Extend Floor

Fingers Flex/Extend Auto

Hip Flex/Extend Static Sitting

BALANCE
LOWER EXTREM.

Abd./Add. Dynamic Sitting

Int. Rot./Ext. Rot. Static Standing

Knee Flex/Extend Dynamic Standing

Propulsion

W/C SKILLS
Ankle Plant./Dors.

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Foot Inver./Ever. Pressure Reliefs
Foot Rests

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AREA STRENGTH ACTION ROM
SPINE

Locks

MANUAL MUSCLE TEST (MMT) MUSCLE STRENGTH

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FUNCTIONAL INDEPENDENCE SCALE (For Balance/Mobility, Self Care/ADL Skills, IADL Skills)

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GRADE DESCRIPTION GRADE DESCRIPTION

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7 Independent.

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5 Normal functional strength - against gravity - full resistance.

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4 Good strength - against gravity with some resistance. 6 Modified independent - verbal cues, extra time.

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3 Fair strength - against gravity - no resistance - safety compromise. 5 Stand-by assist (SBA) - 100% effort w/supervision.
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Poor strength - unable to move against gravity.

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Trace strength - slight muscle contraction - no motion.
4
3
Minimal assist - 75% effort.
Moderate assist - 25-50% effort.
0
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Zero - no active muscle contraction. 2 Maximum assist - 25% effort.

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1 Dependent/unable to do task < 25% effort.
FUNCTIONAL RANGE OF MOTION (ROM) SCALE

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GRADE DESCRIPTION GRADE DESCRIPTION

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Comments: ____________________________________________________
5 100% active functional motion. 2 25% active functional motion.

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_______________________________________________________________
4 75% active functional motion. 1 Less than 25%.

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3 50% active functional motion. _______________________________________________________________

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SUMMARY

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Education/Instruction provided: Safety Exercise Other (Describe) _________________________________________________________________
PT evaluation only. No further indications for PT services

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Was a standardized/validated assessment used? Yes No If yes (specify assessment): __________________________________________________

Orders for PT evaluation only. Needs additional PT services. See PT Care Plan/485 for recommendations.
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Results: ________________________________________________________________________________________________________________________________

0 0
Need to obtain orders: (specify)_________________________________________________________________________________________________________

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Orders for PT services with specific treatments, frequency and duration. See PT Care Plan/485.
Other disciplines providing care: SN OT ST MSW Aide Other:____________________________________________________________
Equipment recommendations: (specify) __________________________________________________________________________________________________
There are no changes to the POC based upon this assessment, at this time.
Was a need identified or reported during this assessment in any of the following areas that requires a referral? Nutrition Medications
Pain Injuries / Wounds Psychosocial concerns Self care skills IADLs Safety issues Other: ________________________________
Yes No If Yes: (specify)___________________________________________________________________________________________________________
Referral recommendations: (specify)_____________________________________________________________________________________________________
Comments: ________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________

DISCHARGE DISCUSSED WITH: Patient Family/Caregiver Care Manager APPROXIMATE NEXT VISIT DATE: ______ /______ /______
Physician Other: _______________________________________________________ PLAN FOR VISIT: ____________________________________
BILLABLE SUPPLIES: N/A Yes (specify)__________________________________ ____________________________________________________
CARE COORDINATION: Physician Nursing PT OT ST MSW ____________________________________________________
Aide Other ____________________________________________________________ ____________________________________________________
SIGNATURES/DATES
Complete TIME OUT (on previous page) prior to signing below.

X
_____________________________________________ ______ /______ /______ _____________________________________________ ______ /______ /______
Patient/Caregiver (if applicable) Date Therapist (signature/title) Date

PHYSICAL THERAPY EVALUATION