2402 Wayne Memorial Drive, Goldsboro NC 27534-1728, (919) 735-1387

485 Worksheet Addendum

Physical Therapy

Patient Name: DOB: Patient ID:

Office: Visit Frequency:

Certification: Recertification:

PT ORDERS
 / PHYSICAL THERAPY EVALUATION
 / PHYSICAL THERAPY TREATMENT
 / ASSESS FOR IMPAIRED MUSCLE STRENGTH OF .
 / ASSESS AND TEACH AMBULATION AND NEEDS FOR ASSISTIVE DEVICES
 / ASSESS AND IDENTIFY NEED FOR MODALITIES
 / ASSESS AND TEACH TRANSFERS
 / ASSESS AND TEACH HEP
 / ASSESS JOINT MOBILITY AND PAIN
 / ASSESS AND TEACH DONN AND DOFF OF PROSTHESIS AND AMPUTATION MANAGEMENT
 / ASSESS AND TEACH BALANCE AND GROSS MOTOR COORDINATION
 / ASSESS ABILITY TO PERFORM SELF CARE
 / ASSESS AND TEACH EDEMA CONTROL
 / ASSESS AND TEACH HOME MANAGEMENT AND ENVIRONMENTAL PRECAUTIONS
 / ASSESS AND TEACH UP AND DOWN STAIRS
 / PATIENT INSTRUCTION IN ASSISTIVE DEVICES
 / WEIGHT BEARING STATUS OPTION
 / ASSESS AND PROVIDE INFRARED THERAPY MODALITY AS INDICATED
PT GOALS
 / PHYSICAL THERAPY GOALS
 / STRENGTH ROM UE
 / 1.INCREASE ROM UE TO TO ASSIST WITH ADL.
 / 2.INCREASE STRENGTH UE TO TO ASSIST WITH ADL.
 / STRENGTH ROM LE:
 / 3.INCREASE ROM LE TO TO ASSIST WITH GAIT AND BALANCE.
 / 4. INCREASE STRENGTH LE TO TO ASSIST WITH GAIT AND BALANCE.
 / GAIT STEPS:
 / 5.PATIENT WILL AMBULATE FEET WITH ASSIST USING TO ALLOW FUNCTIONAL GAIT WITHIN THE HOME.
 / 6.PATIENT WILL AMBULATE FEET WITH ASSIST USING TO ALLOW GAIT TO BATHROOM.
 / 7.PATIENT WILL AMBULATE UP AND OR DOWN STEPS WITH ASSIST USING BALANCE:.
 / 8.PATIENT WILL REQUIRE ASSIST WITH STATIC BALANCE TASKS.
 / 9.PATIENT WILL REQUIRE ASSIST WITH DYNAMIC BALANCE TASKS.
 / 10.PATIENT WILL REQUIRE ASSIST WITH STATIC SITTING TASKS.
 / 11.PATIENT WILL REQUIRE ASSIST WITH DYNAMIC SITTING TASKS.
 / MOBILITY TRANSFERS:
 / 12.PATIENT WILL PERFORM ALL BED MOBILITY WITH ASSIST.
 / 13.PATIENT WILL PERFORM SUPINE TO SIT WITH ASSIST.
 / 14.PATIENT WILL PERFORM SIT TO SUPINE WITH ASSIST.
 / 15.PATIENT WILL PERFORM SIT TO STAND FROM WITH ASSIST.
 / 16.PATIENT WILL TRANSFER FROM TO WITH ASSIST USING .
 / 17.CAREGIVER WILL TRANSFER PATIENT FROM TO WITH ASSIST USING .
 / PATIENT EDUCATION
 / 18.PATIENT WILL BE INDEPENDENT WITH HEP.
 / 19.PATIENT WITH INDEPENDENT RECALL THR
 / PRECAUTIONS.
 / 20.PATIENT WITH INDEPENDENT RECALL HOME
 / SAFETY PRECAUTIONS.
 / 21.PATIENT VERBALIZES UNDERSTANDING OF PHYSICAL
 / THERAPY POT.
 / ADL
 / 22.PATIENT WILL DON OR DOFF AFO WITH ASSIST.
 / 23.PATIENT WILL DON OR DOFF PROSTHESIS WITH ASSIST.
 / 24.PATIENT WILL DON OR DOFF CLOTHING WITH ASSIST.
 / 25.PATIENT WILL BATHE IN WITH ASSIST.
 / 26. DECREASED PAIN/INCREASED SENSATION APPARENT IN LOCATION INFRARED THERAPY MODALITY UTILIZED
HOMEBOUND
 / HOME IS THE APPROPRIATE PLACE FOR CARE DUE TO
 /
  1. DUE TO THE PATIENTS ILLNESS INJURY OR DISABILITY GOING TO AN OUTPATIENT SETTING WOULD CREATE A MEDICAL HARDSHIP BECAUSE ......

 /
  1. GOING TO AN OUTPATIENT SETTING IS CONTRAINDICATED BY THE PATIENTS FRAGILE AND UNSTABLE CONDITION AND THE PHYSICIAN STATES IT WOULD BE UNDESIRABLE OR DETRIMENTAL BECAUSE......

 /
  1. GOING TO AN OUTPATIENT SETTING WOULD INTERFERE WITH THE EFFECTIVENESS OF THE SERVICE BECAUSE......

485 Worksheet Addendum – Physical Therapy rev 10/08Page 1