Assessment – DME – Wheelchair certification

Patient: [textarea cols=40 rows=1]
Sex: [checkbox name="sex" value="male|female"]
DOB: [textarea cols=12 rows=1]
Age: [textarea cols=12 rows=1]
Date of face to face exam: [textarea cols=12 rows=1]
Date of order: [textarea cols=12 rows=1]

DIAGNOSES [textarea cols=20 rows=1]
[checkbox name="diagnosis" value="Cerebral vascular disease I69.398|Congestive heart failure I50.9|COPD J44.9|Dementia F03.90|Degenerative disc disease M51.37|Falling Z91.81|Diabetic neuropathy E11.40|Dialysis Z99.2|Dizziness R42|Fixed hip angle M21.859|Hemiplegia G81.90|Muscle weakness M62.81|Obesity E66.01|Pressure ulcer of buttock L89.3|SCI S14.109A|Osteoarthritis M19.90|Parkinson’s disease G20|Rheumatoid arthritis M06.9|Traumatic brain injury Z87.820|Upper body instability R07.89|Wheelchair bound Z99.3"]

OPTIONS
[checklist name="options" value="Full reclining back|Anti-fold bar|Seat belt|Cane holder|Heel loops|Wheel locks|Anti-tippers"]

HISTORY [textarea cols=20 rows=1]
Historian: [checkbox name="historian" value="patient|family member/facility staff|complete history unobtainable d/t memory loss|complete history unobtainable d/t pain|complete history unobtainable d/t fatigue"]
Time condition(s) present: [textarea cols=20 rows=1]
Setting: [checkbox name="setting" value="living at home|resident at an assisted living facility"]
Maximum distance ambulated independently: [checkbox name="max" value="5 feet|10 feet|20 feet|50 feet"]
Falls: [checkbox name="falls" value="none|occasional|frequent|risk of falls"]
Skin breakdown: [checkbox name="sores" value="present|none currently|history of"]

AMBULATION
Cane: [checkbox name="cane" value="not using|unable to use d/t upper extremity weakness|unable to use d/t upper extremity pain|unable to use d/t lower extremity weakness|unable to use d/t dizziness"]
Walker: [checkbox name="walker" value="not using|limited use d/t fatigue|limited use d/t dizziness|uses with assistance|unable to use independently d/t upper extremity weakness|unable to use independently d/t upper extremity limited range of motion|unable to use independently d/t upper extremity pain with motion|unable to use independently d/t lower extremity weakness"]
Manual wheelchair:
[checkbox name="manual" value="wheeled by staff|unable to use independently d/t upper extremity weakness|unable to use independently d/t dementia"]
Progression of ambulation difficulty over time: [checkbox name="progression" value="improving|deteriorating|unchanged"]

ACTIVITIES OF DAILY LIVING
Reports limited activities of daily living d/t: [checkbox name="adl_limit" value="upper extremity weakness|upper extremity spasticity|lower extremity weakness|lower extremity spasticity|poor standing balance|poor sitting balance|poor coordination|poor endurance evidenced by shortness of breath with exertion|oxygen use|frequent falls|dizziness"]

ADLs requiring assistance of staff:
[checklist name="ADL" value="getting out of bed|dressing|grooming|transfer between bed, chair, & mobility device|toileting|ambulating around facility|ambulating around apartment|feeding"]

PHYSICAL EXAM
Weight: [textarea cols=10 rows=1]
Height: [textarea cols=10 rows=1]
Resting pulse: [textarea cols=10 rows=1]
Exertional pulse: [textarea cols=10 rows=1]
Blood pressure: [textarea cols=20 rows=1]
Respirations: [textarea cols=10 rows=1]
Oxygen saturation: [textarea cols=10 rows=1]

Posture: [textarea cols=40 rows=1]
Tremor: [checkbox name="tremor" value="no|yes"]
Vision: [checkbox name="vision" value="grossly intact|wearing glasses"] 
Hearing: [checkbox name="hearing" value="grossly intact to conversation|hard of hearing|very HOH|wearing hearing aid"]
Cognition: [checkbox name="cognition" value="A/O x3|able to answer questions without difficulty|unable to answer questions"] 
Neck: [checkbox name="neck" value="normal exam|decreased ROM|pain with motion"]
UE: [textarea cols=40 rows=1][checkbox name="ue" value="normal exam|deformity|impaired strength|decreased range of motion|decreased sensation|contracture|dialysis shunt on left|dialysis shunt on right|edema on left|edema on right"]
LE: [textarea cols=40 rows=1][checkbox name="le" value="normal exam|deformity|impaired strength|decreased range of motion|decreased sensation|contracture|edema on left|edema on right"]
Trunk: [textarea cols=40 rows=1][checkbox name="trunk" value="normal exam|kyphosis|weakness|decreased range of motion"]
Sit to stand: [checkbox name="sittostand" value="without difficulty|with significant difficulty|unable to perform independently"]
Gait: [textarea cols=40 rows=1][checkbox name="gait" value="without difficulty|non-ambulatory|shuffling|ataxic|wide|max assist|mod assist|stops every few steps to rest|diaphoresis|tachycardia|tachypnea"]
Skin: [textarea cols=40 rows=1][checkbox name="skin" value="grossly intact|wounds"] 

NARRATIVE
This is a [textarea cols=6 rows=1] y/o patient with several health problems worsening gradually over the past year despite use of multiple medications. Can not perform independently majority of ADLs. Spends more than 2 hours daily in a wheelchair. Mobility limitation cannot be sufficiently resolved by use of cane or walker. Doorways and halls are wide enough for a wheelchair. Willing to use the manual wheelchair at home. Caregiver available and willing to provide assistance with the wheelchair.

CERTIFICATION
I certify that I have the information provided is a true and accurate representation of the patient’s current condition. I have completed a face-to-face examination for the above patient in the last 45 days. I hereby incorporate this document into my patient's medical record.