CLINICAL REPORT
Employee #:
Employee Name:
Report Date:
(MMDDYY)
Patient #:
Patient Name:
(Last, First)
Evaluation Date:
(MMDDYY)
Primary Diagnosis:
Pertinent History:
Caregiver Status:
PT/CG Knowledge Deficit:
HOMEBOUND STATUS
Patient is able to ambulate:
Distance:
10 ft
10-25 ft
25-50 ft
Device:
No device
Walker
Cane
Crutches
Assistance:
Standby
Minimum
Moderate
Maximum
Effort:
Minimum
Moderate
Maximum
Other:
Then must
stop due to:
SOB
Nausea
Dyspnea
Dizziness
Severe pain
Unsteady gait
Poor balance
Lack of endurance
Post surgical complications
Other:
OR:
Patient is essentially bedbound
W/C bound/unable to propel self
Other:
PMH Only:
Patient is unable to leave home due to alteration in mental status
Illness is manifested by a refusal to leave home due to:
Justification for further skilled visits:
Wound size:
Drainage amount:
Color:
Odor:
Pain Severity Information (1-10):
Before Meds:
After Meds:
Location:
Treatment:
REHABILITATION
TRANSFERS TO/FROM
Independent
Minimum
Moderate
Maximum
Unable
Bed, Chair, Toilet
Shower/Tub
Car
Strength & ROM deficit affecting function:
Pain affecting function (scale 1-10):
Area Affected:
ADL Deficits:
Dressing
Bathing
Grooming
Toileting
Eating
Ambulation
Level of Assist
Distance
Assistive Device
Level:
Stairs:
WB Status:
WBAT
NWB
ToeTouch WB
PWB:
%
Distance to Car:
Structural Barriers:
Prior Level of Function:
Treatment:
Goals:
Frequency/Duration
Required:
Ordering MD:
Other Disciplines
Needed/Reason:
DME Needed:
Additional Comments:
© VNA Home Health Systems 2001
