PoC

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Interim Healthcare Services of NEPA Inc.

200 3rd Street, Blakely, PA, 18447-1017 Office: 570-489-6781 | Fax: 570-489-1090

Standard Findings: Vital Signs

Vital Signs Readings

Time:10:27

Respiration
Breaths / minute: 19 rpm
Regular or Irregular:Regular
Activity:Rest/Pre-activity

Blood pressure
Right (systolic / diastolic):(115/73)
Left(systolic / diastolic):
Posture: Sitting
Activity: At Rest

Heart rate
Pulse (beats / minute): 77 bpm
Pulse Location: Radial
Regular or Irregular Pulse: Regular
Activity: Rest/Pre-activity

Temperature
Temperature: 98.0 F
Location: Oral

Comments:

Lung Sounds

Clear

Standard Findings: Pain Status
Pain Assessment

Standard Findings: HomeBound Status
Homebound Status	Indicate condition(s) that prevents patient form leaving home.(Mark all that apply) Bedbound (refer to question M1860) Chairfast and unable to wheel self (refer to question(M1860) Other:ADL dysfunction

Standard Findings: Diabetic Foot Exam Findings
Does this patient with diabetes have	Foot or ankle muscle weakness: Yes An inability to see the bottom of his/her feet: Yes Shoes that are inappropriate in style and fit: No Swelling or an abnormal foot shape: No Elevated skin temperature: No Limited ankle dorsiflexion: Yes Toe nails that are long, thick or ingrown: No Absent pedal pulse: No

Standard Findings: Oxygen
Oxygen	Oxygen Not On Oxygen Pulse Oximetry Level: 97

Functional Status

Functional Mobility / Balance Evaluation

TASK	Evaluation	COMMENTS
Bed mobility
Bed/wheelchair transfer	Minimally Impaired
Toilet transfer
Tub/shower transfer
Dynamic sitting balance	Minimally Impaired
Static sitting balance	Intact
Static standing balance
Dynamic standing balance

Functional Status

Stand to/from Chair: Minimal Assisstance

Discharge
Occupational Therapy Discharge	(Complete this section only upon discharge from Therapy)

Standard Findings: Case Supervision
Case Supervision	N/A - Not Applicable

Therapy Findings
Patient's Subjective Report	Regarding Progress Toward Functional Goals Pt is making progress towards goals. Pt would benefit from continued skilled OT services to maximize the patient’s functional potential.

Dependent Edema

No dependent edema

When is the patient dyspneic or Short of Breath

When walking more than 20 feet, climbing stairs

Orthopnea

Number of pillows required by patient when reclining for sleep: 2 pillows

Skilled Procedures and Teaching

Problems, Interventions, and Goals

ADL/IADL Functional Deficits (11/08/2021, Vermac, Marissa, OT)
Interventions
Assess

ADL Training for bathing :
UE minimal assistance
LE moderate assistance
Comments for Intervention
• Not Performed
Intervention Goals

Describes/demonstrates bathing with appropriate safety, sequencing, and problem solving strategies
By: End of cert period
Percentage of Goal Met:
Comments for Intervention Goal
• - 0-25%

Interventions
Assess/Instruct/Perform

ADL training for Lower Body Dressing for safe functional ability to perform
Moderate assistance
Comments for Intervention
• Not Performed
Intervention Goals

Describes/demonstrates dressing
By: End of cert period
Percentage of Goal Met:
Comments for Intervention Goal
• - 0-25%

ADL Training for Upper Body Dressing for safe functional ability to perform
Minimal assistance
Comments for Intervention
• Not Performed
Intervention Goals

Describes/demonstrates dressing
By: End of cert period
Percentage of Goal Met:
Comments for Intervention Goal
• - 0-25%

Alteration in Transfer Ability (11/08/2021, Vermac, Marissa, OT)
Interventions
Assess/Instruct

Assess ability/instruct transfer to/from toilet
Minimal assistance with sliding board
Comments for Intervention
• Not Performed
Intervention Goals

Demonstrates transfer to/from toilet
By: End of cert period
Status of Goal: Initial
Comments for Intervention Goal
• - 0-25%

Assess ability/instruct transfer to/from shower/tub seat/chair
Moderate assistance with sliding board
Comments for Intervention
• Not Performed
Intervention Goals

Demonstrates transfer to/from shower/tub seat/chair
By: End of cert period
Status of Goal: Initial
Comments for Intervention Goal
• - 0-25%

Patient/Caregiver Teaching Instructions

Document any patient/caregiver teaching provided.

Teaching was presented to

Patient
Caregiver

Teaching Presented

Other Safety Instructions Regarding:Sliding board transfers Response: Good

Patient's Response to Treatment

Check all that apply. If complaint occurred, note action taken and result.

Did not have complaints during treatment.

Patient Progress

No significant decline in status

New symptoms reported?: No
Services are sufficient to meet patient's home care needs: Yes
Patient has desired response to prescribed treatment regimen: Yes
Interventions in the plan of care are appropriate for progressing the patient toward goals.: Yes

** IF NO, ensure physician is aware

Plan For Next Visit

Pt and family will perform ADL and functional transfers on next visit.

(M0018)

National Provider Identifier (NPI) for the attending physician who has signed the plan of care: 1780668533
Physician Name: McCall, DO, Sean
Physician Phone#: 570-342-8500

Patient's Signature
Patient's Signature	Patient's Signature Patient's name: Lawrence Napolitano Patient's signature date: 11/04/2021

Employees Signature

Signature date: 11/04/2021
Employees Signature

Patient Name:	NAPOLITANO, LAWRENCE (1211618)	Date / Time:	11-04-2021 / 10:27 - 11:30
Caregiver Name:	Vermac, Marissa	Status:	Approved & Signed (Version 2)
Form Type:	Occupational Therapy Visit Note - OT	Signature/Date:	Electronically signed by Marissa Vermac, OT, on 11/8/2021

Interim Healthcare Services of NEPA Inc.

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