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