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: Prior Status
Prior Status	MD Visit since last home care visit?: No Falls since last visit?: No Has there been a change in the patient's primary payer in the last 60 days No

Standard Findings: Vital Signs
Vital Signs Readings	Time:11:52 Respiration Breaths / minute: 18 rpm Regular or Irregular:Regular Activity:Rest/Pre-activity Blood pressure Right (systolic / diastolic): Left(systolic / diastolic): Posture: Activity: Heart rate Pulse (beats / minute): 72 bpm Pulse Location: Radial Regular or Irregular Pulse: Regular Activity: Rest/Pre-activity Temperature Temperature: Location: Comments:

Weight

Reported: 175#

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) Unable to negotiate stairs leading to outside( refer to question M1860) Ambulation is unsteady and unsafe even with assistance (refer to question M1860)

Standard Findings: Oxygen
Oxygen	Oxygen Not On Oxygen Pulse Oximetry Level: 98%

Standard Findings: Medications
Medications	No Changes Reported Patient has desired response to prescribed medications regimen(i.e., expected actions, absence of side effects): Yes

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

Therapy Findings
Patient's Subjective Report	Regarding Progress Toward Functional Goals No new c/o. Patient reports doing HEP daily

Dependent Edema

No dependent edema

When is the patient dyspneic or Short of Breath

When walking more than 20 feet, climbing stairs

ROM/Strength/Balance

Balance

Static sit: Good
Dynamic sit: Poor
Static stand: Poor
Dynamic stand: Poor

Skilled Procedures and Teaching
Problems, Interventions, and Goals	Home Exercise Program (11/10/2021, Cianfichi, James, PT) Comments for Problem • - Goal met Interventions Assess/Instruct Assess/instruct home exercise program to enhance range of motion/mobility Comments for Intervention • Performed - Pt demonstrated HEP Intervention Goals Adheres to home exercise program By: 4 weeks Percentage of Goal Met: Comments for Intervention Goal • - Goal Met 100%

Patient/Caregiver Teaching Instructions

Document any patient/caregiver teaching provided.

Teaching was presented to

Patient

Teaching Presented

Other Safety Instructions Regarding:HEP Response: Demonstrated

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?: Yes
Signs/symptoms of exacerbation/worsening of

Recommend larger specialized transport chair with specifications fo be provided by Browns Pharmacy

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
Patient/Caregiver verbalizes indications for discharge: No

** IF NO, ensure physician is aware

Communication

Communicated with Physician: No
Communicated with Other: No

(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

Additional Assessment Comments
Plan For Next Visit	Na

Discharge
Physical Therapy Discharge	(Complete this section only upon discharge from Therapy) Discharge from Therapy Date: 11/10/2021

Patient's Signature
Patient's Signature	Patient's Signature Patient's name: Larry Napolitano Patient's signature date: 11/10/2021

Employees Signature

Signature date: 11/10/2021
Employees Signature

Patient Name:	NAPOLITANO, LAWRENCE (1211618)	Date / Time:	11-10-2021 / 11:10 - 11:55
Caregiver Name:	Cianfichi, James	Status:	Approved & Signed (Version 2)
Form Type:	Physical Therapy Visit Blakely - PT	Signature/Date:	Electronically signed by James Cianfichi, PT, on 11/10/2021

Interim Healthcare Services of NEPA Inc.

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