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Visual acuity - OD - distance
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Visual acuity - OS
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Visual acuity - OU
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Visual acuity OU - near
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Smallest text read (M size)
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Occlusion needed
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If yes, which eye
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Start Time
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End Time
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Diagnosis
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Other relevant medical history
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Precautions/Contraindications
• • •
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Others
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Client Goals/Chief Complaint (Discussed with Client)
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Living situation/Home environment/Social support
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Relevant visual aids currently being used/previous low vision rehab/home care in the past year
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Occupational Performance: Activities of Daily Living
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Self-Report Assessment Functional Visual Performance Outcome Score
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Contrast Sensitivity Chart Results
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Glare Sensitivity
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Optimal Lighting
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Lumen bulb at
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Inches from
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Visual Fields
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Explain
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Ocular motility
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Explain
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Pursuits
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Saccades
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Color vision
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Performance Components – Cognitive
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Orientation
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Attention
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Verbal Communication
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Written Communication
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Reasoning/Insight
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Initiation/Impulsivity
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Learning/Memory
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Performance Components - Physical
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Hearing
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Other
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Speech/language
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Other
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ROM/Strength
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Other
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Fine motor/sensory skills
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Other
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Mobility/balance/activity tolerance
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Other
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Decreased independence in self-care task
• • •
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Prior roles and leisure pursuits are limited due to vision limitations
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Decreased independence in such tasks has resulted in
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Occupational therapy assessment
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Education Provided/Tools Presented this session
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Functional impact of issues identified
• • •
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Written information was provided regarding
• • •
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Demonstration provided
• • •
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Other
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Treatment addressed during evaluation visit
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Goals
|
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Rehab potential
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Recommendations
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Certification period (from)
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Certification period (to)
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Number of anticipated OT visits
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Times per week
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No. of weeks
|
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Discharge / Return
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Information provided on
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Participated in development treatment plan
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If no, explain
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Treatment to include
• • •
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Other treatment
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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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Supervision statement
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