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Local Emergency Dispatch #
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Code Status
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Referring Diagnosis
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Additional notes
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Referring Provider
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ITP PHYSICIAN
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Other relevant medical, surgical, or MSK history
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Learning Barriers
• • •
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Session #
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KX modifier?
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Type
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Exercise
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Stage of Change
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Balance (points total from 3 assessments)
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Semi-tandem Stance time
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side-by-side time
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Tandem stance time
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4m (13.1ft) gait speed (points)
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4 meter walk time
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5x STS (points)
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5xSTS time
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METS
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Fall History (past 6 months)
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Use of Assistive Devices
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ADL/IADL
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Ambulation
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How far can you walk before taking a break?
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SPPB
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DASI
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Resting blood pressure
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Exercise blood pressure
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Anginal symptoms?
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Exercise Plan/Intervention
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Target Heart Rate
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Modality
• • •
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Frequency
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Intensity
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Duration (min)
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Progression
• • •
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Stretching/Resistance Training
• • •
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Goals
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Ex >30min 5d/week
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Resistance Training
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Interval Training
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Resting SBP <120mmHg
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Normotensive Ex response
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Education
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Physical Activity
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Equipment orientation/RPE Scale
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Avoiding Dehydration
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Stretching/ROM
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Resistance Training
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Energy Conservation
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Additional Notes:
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Nutrition Plan
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Nutrition
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Stage of Change
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Most recent labs
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Total Cholesterol
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HDL
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LDL
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Triglycerides
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Creatinine
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HgA1C
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Picture your plate (PYP)
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Intervention
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Monitor weight daily
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Do you own a scale?
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Waist (in)
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Hips (in)
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Ht (in)
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Wt (lbs)
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BMI
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Advised 1-2lb/week weight loss
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Nutrition Counseling
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Advised Na+ <2000mg/day
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Goals
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HgA1C <7% or <6.5% if DM
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BMI <30kg/m2
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LDL <100 or <70 if DM
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HDL >60 W or >55 M
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Patient at goal weight
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Medication compliance?
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Education
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Lowering Cholesterol
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Medication compliance
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Dietary habits with CAD
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What is HgA1C?
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Nutrition consult (date completed)
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Sodium Management
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Heart healthy eating habits
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Mediterranean Diet
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Understanding food labels
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Additional Notes:
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Psychosocial Plan
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Psychosocial
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Stage of Change
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Stress level
/
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PHQ-9
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SF36 Domain Totals
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General Health score
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Total Limitations_Physical Functioning
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Total Physical Health
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Total Emotional Health
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Energy/Fatigue
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Emotional well-being
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Social functioning
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Pain
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Health Change
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Intervention
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Psychotropic medications?
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PCP follow up>?
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Stress management techniques utilized?
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Advised SMART goals
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Goals
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Optimal stress management
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Support system
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Medication compliance
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Education
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Stress management
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Relaxation techniques
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Support Group
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Dealing with setbacks
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Smoking cessation
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SMART goals
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Additional Notes:
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Other core component
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Other core component
• • •
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Other core component
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Stage of Change
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Smoking status
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PPD?
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quit date
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Intervention
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SMART goals?
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Monitor BS at home?
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PCP follow up?
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Goals
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Tobacco Free?
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SMART goals
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Medication compliance?
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Education
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Cardiac arrhythmias
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Breathing exercises
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Inhaler use & exercise
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Reducing alcohol consumption
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Diabetes management
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Intimacy and CAD
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Types of heart surgery
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Additional Notes:
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Impression/Plan
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Exercise:
• • •
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Additional notes (Exercise)
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Nutrition:
• • •
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Additional notes (Nutrition)
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Hyperlipidemia
• • •
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Additional notes (lipids)
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Psychosocial
• • •
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Additional notes (Psychosocial)
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Program follow up
• • •
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Additional Notes:
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Treating CRS:
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