OT GOALS PROBLEM General General General General General Skin Skin Medication Management CODES G01 G02 G03 G04 G05 G01 G02 G01 Medication Management G02 Medication Management Medication Management Medication Management Medication Management Pain Pain Pain Pain Therapeutic Ex-Manual Therapeutic Ex-Manual Therapeutic Ex-Manual Therapeutic Ex-Manual Therapeutic Ex-Manual Therapeutic Ex-Manual Therapeutic Ex-Manual Therapeutic Ex-Manual Therapeutic Ex-Manual Therapeutic Ex-Manual Therapeutic Ex-Manual Therapeutic Ex-Manual Function Function Function Function Function Function G03 G04 G05 G06 G01 G02 G03 G04 G01 G02 G03 G04 G05 G06 G07 G08 G09 G10 G11 G12 G01 G02 G03 G04 G05 G06 DESCRIPTION OT Rehab potential excellent for stated goals OT Rehab potential good for stated goals OT Rehab potential fair for stated goals OT Discharge when goals met or patient no longer meets criteria for services OT Discharge when Patient/caregiver verbalizes understanding of methods to prevent pressure ulcers Patient/caregiver verbalizes methods to prevent skin impairment Patient verbalizes understanding of medication regimen Patient/caregiver demonstrates knowledge of medication dosage, frequency, actions, side effects, and interactions Patient adheres to medication/treatment regimen Patient/caregiver demonstrates ability to manage anticoagulant therapy safely Patient/caregiver demonstrates proper prefill of medication planner Patient/caregiver demonstrates independence in management of injection(s) Patient verbalizes a decrease in pain level from (intensity/location) Patient verbalizes understanding of pain management techniques Patient/caregiver demonstrate effective use of positioning techniques to control pain/pressure Patient/caregiver demonstrates effective use of orthotic device for Patient demonstrates Home Exercise Program (HEP) with Patient demonstrates improved ADL/IADL/mobility by increased ROM of Patient demonstrates improved ADL/IADL/mobility by increased strength of Patient demonstrates increased aerobic capacity/endurance for ADL/IADL's as evidenced by Patient demonstrated improved balance as evidenced by Patient demonstrates improved vestibular signs/symptoms as evidenced by Patient demonstrates improved fluid/edema management as evidenced by Patient will exhibit decreased edema as evidenced by (measurement in cm) Patient demonstrates appropriate application of compression garments/wraps Patient demonstrates improved fine motor coordination as evidenced by Patient demonstrates improved visual/perceptual skills as evidenced by Patient/caregiver demonstrates Patient demonstrates safe bed mobility with Patient transfers safely in/out of tub/shower with Patient transfers safely on/off toilet with Patient transfers safely in/out of bed with Patient transfers safely in/out of chair with Patient transfers safely in/out of wheelchair with ORDER S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S OT GOALS PROBLEM Function Function Function Function Function Function Function Function Function Function Function Function Function Function Function Function (I)ADL (I)ADL (I)ADL (I)ADL (I)ADL (I)ADL (I)ADL (I)ADL (I)ADL (I)ADL (I)ADL (I)ADL (I)ADL (I)ADL (I)ADL Safety Safety Safety Safety Safety CODES G07 G08 G09 G10 G11 G12 G13 G14 G15 G16 G17 G18 G19 G20 G21 G22 G01 G02 G03 G04 G05 G06 G07 G08 G09 G10 G11 G12 G13 G14 G15 G01 G02 G03 G04 G06 DESCRIPTION Patient transfers safely on/off the floor with Patient transfers safely in/out of car with Patient ambulates safely with Patient ambulates steps/curb safely with Patient ambulates ramps safely with Patient ambulates uneven surfaces safely with Patient ambulates even surfaces safely with Patient demonstrates manual wheelchair mobility safely with Patient demonstrates powered wheelchair mobility safely with Patient/caregiver demonstrates safe use of assistive devices/adaptive equipment with Patient demonstrates improved sitting balance as evidenced by Patient demonstrates improved standing balance as evidenced by Patient demonstrates increased gross motor coordination to improve ADL/IADL/ mobility to Patient demonstrates adherence with restrictions and precautions (weight bearing/ROM) Patient/caregiver correctly dons/doffs orthotic/prosthetic safely with Patient demonstrates improved functional cognition as evidenced by Patient performs feeding with Patient performs simple grooming/hygiene with Patient performs oral care with Patient performs toileting hygiene with Patient performs clothing management for toileting with Patient performs upper body dressing with Patient performs lower body dressing with Patient performs sponge bathing in bed with Patient performs sponge bathing in chair with Patient performs showering with Patient performs/participates in meal preparation with Patient performs/participates in laundry with Patient performs/participates in housekeeping with Patient demonstrates safe use of adaptive equipment Patient correctly dons/doffs orthotic/prosthetic with Patient/caregiver demonstrates safe, effective use of equipment Patient/caregiver demonstrates knowledge of fall/safety precautions Caregiver demonstrates proper body mechanics related to patient care Patient/caregiver demonstrates home/fire/oxygen safety techniques Patient maintains level of mobility and participation in ADLs within the limits of disease process ORDER S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S OT GOALS PROBLEM Safety Safety Safety Safety Cognition Cognition Cognition Cognition Cognition Cognition Cognition Cognition Cognition Cognition Cognition Cognition Cognition Cognition Cognition Cognition Cognition Cognition Cognition Cognition Cognition Cognition Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary CODES DESCRIPTION G07 Patient/caregiver demonstrate safe mobility and transfer techniques G08 Patient/caregiver verbalizes/demonstrates proper hand washing technique Patient/caregiver verbalizes/demonstrates compensatory techniques to avoid injury related to sensory G09 impairment G06 Patient maintains level of mobility and participation in ADLs within the limits of disease process G01 Patient demonstrates ability to safely use/manage adaptive equipment in home environment G02 Patient safely performs at highest functional capabilities Patient/caregiver demonstrates knowledge of Allen Cognitive Levels & recommended safety G03 precautions G04 Patient/caregiver demonstrates knowledge of cognitive impairments G05 Patient/caregiver will increase ability to improved insight and safety awareness G06 Patient/caregiver will increase ability to use compensatory strategies for improved cognition at level of G07 Patient will increase ability to sustain attention to tasks with accuracy of G08 Patient will increase ability to divide attention with accuracy of G09 Patient will increase ability to focused attention with accuracy of G10 Patient will increase ability to orient to person, place, time and event with accuracy of G11 Patient will increase ability to solve simple problems with accuracy of G12 Patient will increase ability to solve complex problems with accuracy of G13 Patient will increase ability to utilize effective judgement/reasoning skills with accuracy of G14 Patient will increase ability to sequence functional activities with accuracy of G15 Patient will increase immediate memory skills with accuracy of G16 Patient will increase short term memory skills with accuracy of G17 Patient willl increase working memory skills with accuracy of G18 Patient will increase long term memory skills with accuracy of G19 Patient will increase use of learned compensatory strategies for memory with accuracy of G20 Patient will increase ability to initiate functional tasks with accuracy of G21 Patient will increase ability to inhibit inappropriate/distractive behaviors with accuracy of G22 Patient demonstrates improved functional cognition as evidenced by G01 Patient demonstrates improved activity tolerance for ADL/IADL completion G02 Patient incorporates breathing strategies into daily activities G03 Patient demonstrates decreased dyspnea with ADL/IADL G04 Patient/caregiver demonstrates utilization of energy conservation techniques and pacing with ADL/IADL G05 Patient demonstrates safe use of assistive and adaptive equipment with ADL/IADL G06 Patient demonstrates adequate oxygenation in ADL/IADL as evidenced by PA02 G07 Patient/caregiver demonstrates/verbalizes understanding of proper/safe use of oxygen and related equipment G08 Patient/caregiver verbalizes understanding of sternal/cardiac precautions ORDER S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S OT GOALS PROBLEM Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary Cardiopulminary CODES G09 G10 G11 G12 G13 G14 G15 G16 G17 G18 G19 G21 G22 G23 G24 G25 G26 G27 G28 G29 G30 G31 G32 G33 G34 G35 G36 G37 G38 Cardiopulminary G39 Cardiopulminary Low Vision Low Vision Low Vision Low Vision G40 G01 G02 G03 G04 DESCRIPTION Patient/caregiver demonstrates independence in upper extremity endurance exercise/HEP Patient maintains stable cardiovascular status at baseline within parameters Patient has reduced episodes of chest discomfort Patient has reduced episodes of shortness of breath Patient/caregiver verbalizes signs/symptoms of cardiac disease Patient verbalizes methods to decrease edema Patient will monitor and record weight daily and report if outside of ordered parameters Patient/caregiver demonstrates understanding of proper use of cardiac medications and side effects Patient is compliant with low sodium heart healthy diet Patient is compliant with fluid restrictions and intake monitoring Patient/caregiver demonstrates proper prefill of medication planner Patient transfers safely on/off toilet with Patient transfers safely in/out of bed with Patient transfers safely in/out of chair with Patient transfers safely in/out of wheelchair with Patient transfers safely on/off the floor with Patient transfers safely in/out of car with Patient demonstrates safe bed mobility with Patient demonstrates increased balance as evidenced by improved score of (TUG/Tinetti/BERG) Patient/caregiver demonstrates safe use of assistive devices with Patient correctly dons/doffs orthotic/prosthetic safely with Patient correctly dons/doffs cast/splint safely with Patient demonstrates independent static sitting balance with Patient demonstrates independent dynamic sitting balance with Patient demonstrates independent static standing balance with Patient demonstrates independent dynamic standing balance with Patient demonstrates improved aerobic capacity as evidenced by Patient demonstrates proficiency in use of HELP system Patient demonstrates safe functional household mobility using least restrictive ambulating device Patient/caregiver demonstrates understanding on how to decrease exacerbation of disease process and risk of thrombus Patient will demonstrate adequate surgical wound healing Patient/caregiver demonstrates appropriate low vision strategies Patient/caregiver demonstrates adequate competency in use of adaptive equipment Patient/caregiver communicates understanding of the benefits of home modification Patient/caregiver communicates knowledge of available community resources and how to access ORDER S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S OT GOALS PROBLEM Low Vision Low Vision Low Vision Low Vision Low Vision Low Vision Neuro CODES G05 G06 G07 G08 G09 G10 G01 Neuro G03 Neuro Neuro G04 G05 Neuro G06 Neuro G07 Neuro Neuro Neuro Neuro Neuro G08 G09 G10 G11 G12 DESCRIPTION Patient/caregiver communicates knowledge of resources and educational materials provided Patient/caregiver demonstrates the use of Preferred Retinal Location (PRL) Patient demonstrates understanding of Home Exercise Program to include Pre-Reading and writing exercises Patient/caregiver verbalizes understanding the importance of using optical devices as prescribed Patient/caregiver verbalizes understanding of maintenance/proper care of optical devices Patient demonstrates safety in performing ADL's and IADL's to include functional Mobility Patient/caregiver applies compensatory strategies for perceptual deficits in ADL/IADLs Patient/caregiver show good return demonstration of HP for perceptual retraining/remediation in ADL/IADL Patient/caregiver communicates/demonstrates understanding positioning to normalize tone Patient/caregiver demonstrates competence in HEP Patient/caregiver communicates/demonstrates understanding of positioning for prevention of contractures Patient/caregiver communicates understanding and demonstrates application of methods to reduce falls during ADLs/IADLs Patient/caregiver demonstrates competent use of adaptive equipment during ADLs/IADLs Patient will demonstrate reduction in abnormal muscle tone as evidenced by Patient will demonstrate improvement in normal movement patterns as evidenced by Patient/caregiver will demonstrate understanding of strategies to compensate for sensory loss Patient/caregiver will demonstrate understanding of strategies to compensate for tremors ORDER S S S S S S S S S S S S S S S S S
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