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Impairment Code
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Primary Diagnosis
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Secondary Diagnosis
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Visual acuity OD 20/
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Visual acuity OS 20/
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Visual acuity OU 20/
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Pertinent Medical History:
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Age
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Doctors name
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Date of initial low vision clinic exam
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Gradual /sudden onset of visual decline
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How many months client has struggled with vision
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Pt. is most frustrated with functional deficits related to
• • •
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Additional comments
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Number of visits since start of care:
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OT sessions
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Number of home visits
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Number of hours
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Additional services may be necessary
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Functional status and disposition at end of care:
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Functional status at end of care comments
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Goals
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Written or verbal information provided during visit:
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Written or verbal information provided during visit
• • •
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Comments
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Demonstration provided in above as well and patient participated in:
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Demonstration provided in above as well and patient participated in:
• • •
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Comments
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Equipment provided:
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Equipment provided
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Overall success toward goals
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Devices currently used to complete ADLs
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Registered/given info for community resources
• • •
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Optical devices, non-optical devices and resources were considered but not acquired
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Self-report Assessment of Visual Function Performance (SRAFVP) score
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Number of relevant measures:
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Composite score:
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Percentage of disability:
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Occupational Therapy Student
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Occupational Therapist
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OT/Low Vision Specialist
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NPI
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Certification
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Supervision statement
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