Lifelong Therapeutics / Balanced Rehab<br />Occupational Therapy
Note Type
*
Evaluation
10th Visit Progress Note
20th Visit Progress Note
30th Visit Progress Note
Progress Note
Discharge Summary
Re-evaluation
Maintenance Report
Patient Name
*
Last Name
First Name
Location
Please Select
Brandywine Savoy
The Fountains at Rivervue
The Mews of Greenwich
Maplewood of Darien
Atria of Darien
Maplewood at Strawberry Hill
Maplewood at Orange
Maplewood at Newtown
Maplewood at Stony Hill
Maplewood at Danbury
Maplewood at Weston
Brookhaven Townhouse
Sunrise of Smithtown
Bristal of Westbury
Epoch of Weston
Bridges of Trumbull
Waterstone at Wellesley
Traditions of Wayland
Bridges by Epoch Westwood
White Oak Cottages
Cedar Woods
Wyndham Falls Estates
Private Home
Apt / Rm
Patient is in private address
Yes
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Info
Primary Contact
First Name
Last Name
Contact E-mail
Contact Phone
Date of Birth
-
Month
-
Day
Year
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Primary Insurance
Secondary Insurance
Physician
Physician Phone
Rational for necessity of skilled therapeutic intervention
Subjective
I can't walk very well
My legs feel weak
I need to stop and rest
I feel weak
I feel dizzy
I have trouble getting up from the chair.
Sometimes I feel like I lose my balance
I feel like I'm going to fall
Reports pain in knees
Reports pain in foot
Reports pain in hip
Reports pain in back
I have no energy
I feel tired
I don't get tired as easily
I feel my balance is improving
I feel more confident
I feel I'm getting stronger
I feel my legs are getting stronger
I still have pain but can move better
My pain is less
I can get around the bathroom more easily
I can manage better in the kitchen
I can get in and out of closet more easily
I can get in and out of bed easier
I need less help getting dressed
I feel safer walking
I need less help in the shower
I need less help in the bathroom
Subjective Comment
Objective Findings 1
Prior Level of Function
Independently ambulating w/ no device and all ADLs and higher level functional skills
Independent ambulation w/ rolling walker and all ADLs and higher level functional skills
Indepenently ambulating w/ rolator and all ADLs and higher level functional skills
Ambulated w/ supervision w/ RW and required < 20% assist w/ ADLs.
Ambulated independently w/ RW and required < 20% assist w/ ADLs.
Ambulated short distance w/ RW and requires 20% assist w/ ADLs.
Ambulated short distance w/ RW and requires 30% assist w/ ADLs.
Ambulated short distance w/ RW and requires 40% assist w/ ADLs.
Ambulated w/ cane and required 10% assist w/ ADLs.
Ambulated w/ cane and required 20% assist w/ ADLs.
Utilized W/C for distances ambulated w/ RW to meals, bathroom and short distances.
Able to transfer/ambulate with RW = 20% assist
Required 20% assist for transfers and bed mobility.
Required 30% assist for transfers and bed mobility.
Required 40% assist for transfers and bed mobility.
Required 50% assist for transfers and bed mobility.
Required 60% assist for transfers and bed mobility.
Prior Level of Function
Hand Dominance
Right
Left
Ambedextrous
Vital Signs
Memory
Intact for all faculties
Mild memory loss
Memory impaired. Effects safety, goes with out device.
Difficulty recalling info after 30 seconds
Difficulty recalling info after 1 minute
Difficulty recalling info after 5 minutes
Follows directions appropriately
Moderately impaired, aware of caregivers and surroundings, unaware of risks
Attention
Please Select
Attends to task well w/out redirection
Requires verbal cues to stay on task
Easily distractable, loses focus on task, & requires frequent redirection
Verbal Cues
Remember to use rolling walker
Maintain or correct posture
Expand stride
Lift feet to improve ground clearance during ambulation
Be aware of obstacles
Attend to task
Use pursed lip breathing techniques
Reach back for chair when sitting
Use device while in apartment
Maintain hip precautions
Verbal/Tactile Cues/Assist
Judgement
Please Select
Makes sound decisions
Mildly impaired can be impulsive at times
Impaired. Disregards safety reccomendations. Increased fall risk
Inconsistently requires supervision to avoid attempts to ambulate w/out assistance
Behavior
Please Select
Pleasant
Cooperative
Motivated
Highly motivated
Anxious
Fearful
Lethargic
Agitated
Insight
Please Select
Aware of abilities and limitations.
Aware of medical conditions however does not recognize impact on physical limitations and safety
Unaware of limitations and risks
Significantly limited and unaware of functional limitations and risks.
Precautions
Please Select
Increased risk for fall
High risk for fall
Total hip precautions
Cardiac precautions
Monitor oxygen level
Orthostatic hypotension
Vertigo
Fragile joint precautions
Sensory
Please Select
Impaired kinesthetic awareness
Visual impairment causes safety risk
Impaired tactile sensation in upper body
Impaired sensation and proprioception in lower extremity
Impaired vision causes increased difficulty seeing obstacles.
Vision severely impaired greatly increased risk of falls
Impaired awareness of obstacles
Decreased lower body sensation due to peripheral neuropathy
Impaired awareness of posterior loss of balance.
Objective Findings 2
Pain location 1
Please Select
Hand
Elbow
Shoulder
Neck
Back
Hip
Knee
Foot
Side of body
Please Select
Right
Left
Center
Bilaterally
Pain Scale
Please Select
0
1
2
3
4
5
6
7
8
9
10
Pain location 2
Please Select
Hand
Elbow
Shoulder
Neck
Back
Hip
Knee
Foot
Side of body
Please Select
Right
Left
Center
Bilaterally
Pain Scale
Please Select
0
1
2
3
4
5
6
7
8
9
10
Pain location 3
Please Select
Hand
Elbow
Shoulder
Neck
Back
Hip
Knee
Foot
Side of body
Please Select
Right
Left
Center
Bilaterally
Pain Scale
Please Select
0
1
2
3
4
5
6
7
8
9
10
Deficits in Upper Body PROM / AROM
Please Select
Within functional limits for functional activities
Range of motion in shoulders impaired and limits ability to complete ADLs
Range of motion in hands impaired and limits ability to complete ADLs
Arthritic deformities of the hand causing incr difficulties to perform ADLs
Nonfunctional contracture of the hand
Nonfunctional contracture of the elbow
Multiple arthritic deformities of the hand
Deficits in Postural range of motion
Please Select
Deformity of neck causing increase risk of fall and difficulty performing self care skills
Deformity of back causing increase risk of fall and difficulty performing self care skills
Non fixed deformity of the back causing increase risk of fall and difficulty performing self care skills
Decreased ability to maintain erect posture due to weakness.
Forward COG causing increased risk for fall.
Core weakness causes inability to maintain posture and keep pace with walker
Deficits in Lower Extremity range of motion
Please Select
Decreased range of motion of the knee causing difficulty maintaining standing and safe ambulation
Decreased range of motion of the hip causing difficulty maintaining standing and safe ambulation
Decreased ankle dorsiflexion causing increased risk for fall
Range of Motion (Other)
Functional Strength
Functional Strength with Weakness in
Right upper body
Left upper body
Hands
Trunk / Core
Bilateral upper body
Hip ext / abd / add
Quads / hamstring / lower leg
Shoulders in flex/abd/int and ext Rotation
Functional Weaknesses limit performance of
UB Dressing
LB dressing
Sit to stand
Retrieving clothes
Feeding setup
Bed mobility
Kitchen access
Grooming
Making bed
Carrying adl objects
Food and drink
Washing self
Management of door while ambulating
Ambulatory Device
Ambulates without use of assistive device
Straight cane
Quad cane
Rolling walker
Hemi walker
Rollator
Wheelchair
U-Step walker
Ambulates w/out use of device due to poor judgement or memory
Gross motor
UB Intact
UB Impaired for ADLs
UB Slow speed of movement
LB Intact
LB Impaired/varied planes
LB Slow speed of movement
Sit to stand/difficulty coordinating rocking for momentum and initiating push to stand
Impaired for lower body moving in varied planes
Impaired protective reflexes with potential to loose balance while moving in varied planes
Rigid muscle tone restricting smooth movement in UB, LB and trunk mobility.
Increased difficulty to initiate movement, to step protectively and prevent falls
Frequently looses balance to posterior
Fine motor
Please Select
Intact
Impaired R for ADLs
Impaired L for ADLs
Impaired bilateraly for ADLs
Difficulty manipulating fasteners and opening containers
Difficulty holding utencils
Difficulty using non dominant hand
Sitting balance
Please Select
Intact for ADLs
Unable to safely reach down to wash or dress feet during ADLs
Looses balance reaching laterally
Unable to sit unsupported
Impaired as per seated functional reach test
Standing balance
Please Select
Intact static standing
Intact dynamic standing
Impaired as per Functional Reach test
Impaired as per modified Berg Bal test
Impaired as per Timed Up and Go test
Unable to maintain balance w/out guarding
Unable to maintain balance w/out physical assist
Unable to stand unsupported
Coordination & motor control impaired to perform
UB Dressing / in unsupported sitting
LB Dressing / in unsupported sitting
Sit to stand
Retrieving / putting away clothes
Feeding
Bed mobility
Accessing items in kitchen and closets
Grooming
Making bed
Carrying objects/ADLs
Food and drink
Washing self
Wheelchair mobility
During ambulation in apartment
While ambulating on uneven surfaces
To negotiate stairs
Adaptive devices
Arm frame for toilet
Grab bars in shower
Bed enabler bar
Shower seat
Reacher, long shoe horn, sock aide,
Built up handle feeding utensils
AFO
Right Hand brace
Right Knee brace
Right Wrist brace
Back support/brace
Left Hand brace
Left Knee brace
Left Wrist brace
Left Back support/brace
Functional Outcome Measures
Barthel ADL Index
Test Performed
Barthel ADL Index Results
Timed Up and Go
Test Performed
Time of over 18 seconds indicates increased risk for fall.
Timed Up and Go Results
Five Times STS
Test Performed
Five Times STS Results
DASH Test
Test Performed
DASH Test Results
Modified Berg Bal
Test Performed
1- Standing unsupported with eyes closed. Instructions: “Close your eyes and stand still for 10 seconds”
Please Select
0: Needs help to keep from falling
1: Unable to keep eyes closed for 3 seconds but remains steady
2: Able to stand for 3 seconds
3: Able to stand for 10 seconds without supervision
4: Able to stand for 10 seconds safely
2- Stand unsupported with feet together. Instructions: “Place your feet together and stand without holding on to anything”
Please Select
0: Needs help to attain position and unable to hold for 15 seconds
1: Needs help to attain position but able to stand for 15 seconds with feet together
2: Able to place feet together independently but unable to hold for 30 seconds
3: Able to place feet together independently and stand for 1 minute without supervision
4: Able to place feet together independently and stand for 1 minute safely
3- Reaching forward with outstretched arm. Instructions: “Lift you arm to 90 degrees. Stretch out your fingers and reach forward as far as you can” (Examiner places a ruler and end of fingertips when arm is at 90 degrees. Fingers should not touch the ruler while reaching forward. The recorded measure is the distance toward that the fingers reach while the person is in the most forward lean position.)
Please Select
0: Needs help to keep from falling
1: Reaches forward but needs supervision
2: Can reach forward more than 2 inches safely
3: Can reach forward more than 5 inches safely
4: Can reach forward confidently more than 10 inches
4- Pick up object from the floor from a standing position. Instructions: “Please pick up the shoe/slipper that is placed in front of your feet”
Please Select
0: Unable to try/needs assistance to keep from losing balance or falling
1: Unable to pick up shoe and needs supervision while trying
2: Unable to pick up shoe but comes within 1-2 inches and maintains balance Independently
3: Able to pick up shoe but needs supervision
4: Able to pick up shoe safely and easily
5- Turn to look behind over left and right shoulders while standing. Instructions: “Turn you upper body to look directly over your left shoulder. Now try turning to look over you right shoulder”
Please Select
0: Needs assistance to keep from falling
1: Needs supervision when turning
2: Turns sideways only but maintains balance
3: Looks behind one side only; other side shows less weight shift
4: Looks behind from both sides and weight shifts well
6- Turn 360. Instructions: “Turn completely in a full circle. Pause, then turn in a full circle in the other direction”
Please Select
0: Needs assistance while turning
1: Needs close supervision or verbal cueing
2: Able to turn 360 safely but slowly
3: Able to turn 360 safely to one side only in less than 4 seconds
4: Able to turn 360 in less than 4 seconds to each side
7- Place alternate foot on bench or stool while standing unsupported. Instructions: “Place each foot alternately on the bench (or stool). Continue until each foot has touched the bench (or stool) four times”. (Recommended use of 6- inch-high-bench.)
Please Select
0: Needs assistance to keep from falling/unable to try
1: Able to complete fewer than two steps; needs minimal assistance
2: Able to complete four steps without assistance but with supervision
3: Able to stand independently and complete eight steps in more than 20 seconds
4: Able to stand independently and safely and complete eight steps in less than 20 seconds
8- Stand unsupported with one foot in front. Instructions: “Place one foot directly in front of the other. If you feel that you can’t place your foot directly in front, try to step far enough ahead that the heel of your forward foot is ahead of the toes of the other foot” (Demonstrate this test item)
Please Select
0: Loses balance while stepping or standing
1: Needs help to step but can hold for 15 seconds
2: Able to take small step independently and hold for 30 seconds
3: Able to place one foot ahead of the other independently and hold for 30 seconds
4: Able to place feet in tandem position independently and hold for 30 seconds
9- Standing on one leg. Instructions: “Please stand on one leg as long as you can without holding onto anything”
Please Select
0: Unable to try or needs assistance to prevent fall
1: Tries to lift leg, unable to hold 3 seconds but remains standing independently
2: Able to lift leg independently and hold up to 3 seconds
3: Able to lift leg independently and holds for 5 to 10 seconds
4: Able to lift leg independently and hold more than 10 seconds
Modified Berg Results
Functional Reach Test
Test Performend
Functional Reach Results
Arm Curl Test
Test Performed
Arm Curl Results
Patient Specific Functional Scale
Test Performed
Patient Specific Functional Scale
Clinical Functional Assesment
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Stand pivot transfer
Transfer sit to stand
Sit to stand w/out arms
Toileting w/ arm frame
Toileting w/out arms
Upper body dressing
LB dressing pants
LB dressing footwear
Supine/sit
Reposition in bed
Rolling
Grooming standing
Grooming seated
Feeding
Feeding setup
Bathing standing
Bathing seated
Carrying ADL objects
Kitchen access
Closet access
Making bed
Total % of Functional Complexity / Does not include areas marked as N/A or 0% (add average % from above
Total % of Assistance with Functional Mobility / Does not include areas marked as N/A or 0%
Progress Acheived
Total % of Functional Complexity / Does not include areas marked as N/A or 0%
Please Select
N/A
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Wheelchair mobility
Ambulation in Apt w/o device
Ambulation in home
Access in community
Light housekeeping
Stair Climbing
Functional Short Term Goals
Functional Long Term Goals
Functional Reporting
Current
Please Select
Self Care - G8987
Walking/Moving - G8978
Changing Position - G8981
Carrying/Moving Object - G8984
Modifier
Please Select
CH 0%
CI 1-19%
CJ 20-39%
CK 40-59%
CL 60-79%
CM 80-99%
CN 100%
Goal
Please Select
Self Care - G8988
Walking/Moving - G8979
Changing Position - G8982
Carrying/Moving Object - G8985
Modifier
Please Select
CH 0%
CI 1-19%
CJ 20-39%
CK 40-59%
CL 60-79%
CM 80-99%
CN 100%
Discharge
Please Select
Self Care - G8989
Walking/Moving - G8980
Changing Position - G8983
Carrying/Moving Object - G8986
Modifier
Please Select
CH 0%
CI 1-19%
CJ 20-39%
CK 40-59%
CL 60-79%
CM 80-99%
CN 100%
FINAL / SUBMIT
Recommended Plan
Please Select
Restorative OT Program
Maintenance OT Program
No further services
Therapist Name
Please Select
Justin Chacko, OTR
Susan Demark, OTR
Kirstin Luke, COTA
Jeffery Ciolino, OTR
Allan Meyer, OTR
Jeanne Dorr, OTR
Jeanne Kellogg, COTA
Justin Chacko, OTR
Nancy Schulz, COTA
Alana Malek OTR
Teresa Smith OT
James Clifford COTA
Maria Loureiro OT
Joice Joseph OTR
Karen Tornifoglio OTR
Denise Butt, OTR
Michelle Barresi, OTR
Anthony Cipoletti OTR
Michelle O'Connor OTR
Sarah Guariglia OTR
Kathryn Williams OTR
Therapist Email
*
Please Select
susan.lifelong@gmail.com
kirstin.lifelong@gmail.com
jeff.lifelong@gmail.com
jeanne.lifelong@gmail.com
jkellogg.lifelong@gmail.com
Justin.lifelong@gmail.com
nschulz.lifelong@gmail.com
alana.lifelong@gmail.com
teresasmith.lifelong@gmail.com
jimclifford.lifelong@gmail.com
mloureiro.lifelong@gmail.com
joice.lifelong@gmail.com
ktornifoglio.lifelong@gmail.com
mbarresi.lifelong@gmail.com
denise.lifelong@gmail.com
anthony.lifelong@gmail.com
moconnor.lifelong@gmail.com
sarah.lifelong@gmail.com
kwilliams.lifelong@gmail.com
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