M & M HOME CARE: THERAPY VISIT NOTE OT / PT / ST

1Treatment > 2Billing & Signature > 3Review Your Entry
DISCIPLINE
PATIENT NAME PATIENT NAME First Last
PATIENT DOB: PATIENT DOB: / MM / DD YYYY
TREATMENT DATE: TREATMENT DATE: / MM / DD YYYY
TREATMENT STARTED TREATMENT STARTED : HH MM AM/PM
TREATMENT ENDED TREATMENT ENDED : HH MM AM/PM
LOCATION OF TREATMENT

LOCATION OF TREATMENT HOME VISIT (12) OFFICE VISIT (11) TELEHEALTH - IN HOME (10) TELEHEALTH - NOT IN HOME (02) ASSIST LIVING FACILITY (13) GROUP HOME (14) TEMPORARY LODGING (16) PLACE OF EMPLOYMENT (18) SKILLED NURSING FACILITY (31) NON SKILLED NURSING FACILITY (32) OTHER (99) OTHER (99)
PPE WORN
THERAPIST PPE

THERAPIST PPE N-99 FACIAL MASK N-95 / KN-95 MASK SURGICAL MASK GLOVES FACIAL SHIELD ISOLATION GOWN SHOE COVERINGS OTHER OTHER
PATIENT WAS OFFERED A PROCEDURE MASK TO WEAR FOR TREATMENT:

PATIENT WAS OFFERED A PROCEDURE MASK TO WEAR FOR TREATMENT: PATIENT ACCEPT AND WORE THROUGHOUT THE ENTIRE TREATMENT PATIENT DECLINED TO WEAR A PROCEDURE MASK. WAS EDUCATED RE: PURPOSE /REASONING BUT STILL DECLINED
ASSESSMENT
VITALS
B/P
PULSE
RESPIRATION
SpO2
HOME THERAPY PROGRAM ESTABLISHED?
PARTICIPATION & FOLLOW THROUGH BETWEEN VISITS:

PARTICIPATION & FOLLOW THROUGH BETWEEN VISITS: ADEQUATE INADEQUATE NOT APPLICABLE OTHER OTHER
% OF FOLLOW THROUGH IF APPLICABLE
Must be a number less than or equal to 100.
BEHAVIORAL / MENTAL STATUS
ALERT ORIENTED ANXIOUS FEARFUL LETHARGIC APATHETIC NON-COMPLIANT DISTRACTED TANGENTIAL PERSEVERATIVE DIS-INHIBITED NEURO-FATIGUED MOTIVATED LABILE AGITATED LOW FRUSTRATION TOLERANCE EUTHYMIC OTHER OTHER
PAIN
FREQUENCY OF PAIN

FREQUENCY OF PAIN 0 - HAS NO PAIN 1 - HAS PAIN THAT DOES NOT INTERFER WITH ACTIVITY OR MOVEMENT 2 - LESS OFTEN THAN DAILY 3 - DAILY BUT NOT CONSTANT 4 - ALL OF THE TIME
INTENSITY OF PAIN
QUALITY OF PAIN

QUALITY OF PAIN Shooting Sharp Electric Hot Radiating Aching Heavy Dull Cramping Throbbing Other Other
PAIN SITE(S)
AGGRAVATING FACTORS
ALLEVIATING FACTORS
SKIN
NO DEFICIT
WOUND PRESENT
IF WOUND PRESENT - PROVIDE DESCRIPTION
SKIN ASSESSMENT

SKIN ASSESSMENT Warm Hot Cold Cool Dry Clammy Diaphoretic Other Other
SAFETY
FALL PRECAUTIONS MAINTAINED?

FALL PRECAUTIONS MAINTAINED? YES NO UNKNOWN
ANY FALLS SINCE LAST VISIT?

ANY FALLS SINCE LAST VISIT? YES NO UNKNOWN
ANY MEDICATION CHANGES SINCE LAST VISIT?

ANY MEDICATION CHANGES SINCE LAST VISIT? YES NO UNKNOWN
ANY SIGNIFICANT HEALTH CHANGES SINCE LAST VISIT?

ANY SIGNIFICANT HEALTH CHANGES SINCE LAST VISIT? YES NO UNKNOWN
IF "YES" TO ANY OF THE ABOVE - PLEASE DESCRIBE:
SUBJECTIVE STATEMENT
TREATMENT
PATIENT TEACHING
PATIENT RESPONSE TO THERAPY / TEACHING
MEASURABLE PROGRESS TO GOALS
EQUIPMENT PROVIDED TO PATIENT
WAS EQUIPMENT PROVIDED TO THE PATIENT THIS VISIT?
BILLING CODE
DESCRIPTION
QUANTITY
COMMUNICATION
COMMUNICATION WITH INTERDISCIPLINARY TEAM
COMMUNICATION WITH:

COMMUNICATION WITH: SN PT OT SLP CASE MGR HHA FAMILY OTHER OTHER
COMMUNICATION REGARDING:
PHYSICIAN COMMUNICATION
COMMUNICATION WITH PHYSICIAN
NAME OF PHYSICIAN CONTACTED:
DATE DATE / MM / DD YYYY
TIME TIME : HH MM AM/PM
ORDER CHANGES
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M & M HOME CARE: THERAPY VISIT NOTE OT / PT / ST

M & M HOME CARE: THERAPY VISIT NOTE OT / PT / ST

PPE WORN

ASSESSMENT

BEHAVIORAL / MENTAL STATUS

PAIN

SKIN

SAFETY

SUBJECTIVE STATEMENT

TREATMENT

PATIENT TEACHING

PATIENT RESPONSE TO THERAPY / TEACHING

MEASURABLE PROGRESS TO GOALS

EQUIPMENT PROVIDED TO PATIENT

COMMUNICATION

PHYSICIAN COMMUNICATION

PLAN FOR NEXT VISIT