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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

Occupational Therapy LV Discharge Summary Medical Form

Other

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Published: Dec. 8, 2019, 9:39 p.m.
Doctor: Dr. History Physical
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