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Examination

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  1. Include the current medical diagnosis and any relevant secondary medical diagnoses or test results. The relevant secondary medical diagnosis can help justify the need for examination of a patient's functional level, even if the patient does not need prolonged OT or PT.

  2. The onset of the current medical diagnosis and the date that therapy began are essential to the initial evaluation note and will also be referred to in the re-evaluation/progress and D/C note.

  3. Do not list irrelevant information. Information from the patient or significant other(s) should help demonstrate the need for therapy.

  4. When reporting complaints, keep the complaints brief and to the point. What does the patient see as his or her biggest complaint or concern? How does this complaint/concern tie into patient performance of activities and participation (if the complaint/concern itself is not functional)?

  5. Have the patient rate his or her complaints on a scale. Subjective information put on a type of scale or measured with an evidence-based tool can be used to re-evaluate the patient's progress over the course of therapy. A pain scale is one example. Functional abilities at home and the amount of assistance the patient required to complete them (e.g., the number of people needed) is another. Subjective information put on a type of scale or measured with an evidence-based tool can be used to re-evaluate the patient's progress. Use a quality-of-life scale if possible.

  6. Avoid listing nonspecific complaints in progress notes that are the result of possible patient discouragement. Statements such as “I don't think I'm doing very well” may serve as a red flag to the reviewers and may not be validated by the results of objective tests and measures.

  7. Do list the patient's level of functioning prior to the onset of his or her current diagnosis. This can help justify the need for therapy in the case of a chronic illness. It can also justify the need for teaching by the therapist. (For example, a patient who has never used a walker before needs instruction in its proper use.)

  8. Do briefly describe the patient's living environment, social history, and employment status and environment. Does the patient live alone? Who will be available and for what duration to care for the patient, if needed? Are there steps present, to access the patient's residence or bedroom and main bathroom and is there a handrail? Are the steps essential for the patient to ambulate? What is the distance from the bed to the bathroom, to the kitchen, and so forth? Are the surfaces on the floors carpeted, tiled, linoleum, or hardwood, and are throw rugs present? Are there grab bars in the bathroom around the toilet or tub? Can a wheelchair fit through the doorways and turn in the rooms, if needed?

  9. Briefly list any relevant history from the patient under the appropriate subcategories. Has the patient's functional status declined recently? If so, why? Include whether the patient has received therapy before, why, and when. Has ...

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