1.2 Objective Patient Assessment

1.2       Objective Patient Assessment

May involve any or all of the following codes:

Code Procedure Description
1 Physical Exam May include but is not limited to the following:

Evaluation of skin condition and integrity including: wound presence, topical skin pathology, edema, redness, tissue density, scarring, redundant tissue, neuromas or sensitivities, bony deformities, prominences and landmarks, adhesions, abrasions,

vascularization (skin temperature, capillary refill, hair growth and discoloration)),

Proprioception, sensation, muscle(s) strength, joint(s) Range Of Motion (ROM), joint contracture, joint stability, joint centre location, reflexes or trigger points, U/E (upper extremity) function(s), L/E (lower extremity) function(s), pain, tone, clonus, spasticity, body weight and height, any other musculo-skeletal concern.

2 Static Functional Evaluation (without prosthesis/orthosis) Evaluation of entire body position and posture, support and alignment under non-weight bearing or static conditions without prosthesis/orthosis.

Comparison of affected body segment to non-affected body segment and/or norms, measure deviation from normal posture, or balance if applicable. May include evaluation of: anatomical alignment, pathological alignment or rotation(s), anatomical relationships and/or joints under static conditions in frontal, sagittal, and transverse planes, balance, limb volume, coordination/symmetry, head control, respiratory function and the ability to stand or sit.

3 Dynamic Functional Evaluation (without prosthesis/orthosis) Evaluation of entire body position and posture, support and alignment under weight bearing or dynamic conditions.

Comparison of affected segment to non-affected segment and/or norms, measure deviation from normal posture, balance, changes in tone with movement, functional position for ADL’s/driving/communication tools and head control.

This can also include assessment of patient’s ability to transfer, fatigue issues and functional strength.

May include evaluation of:

Anatomical relationships and/or joints under dynamic conditions, limb volume, dynamic balance, coordination/symmetry, footwear and use of gait aids, mobility using observational gait analysis in frontal, sagittal, and transverse planes or demonstration of activities of daily living (ADL).

4 Static Functional Evaluation (with prosthesis/orthosis) Assess functional use of prosthesis/orthosis under non-weight bearing and/or weight-bearing static conditions.

Evaluation of intimacy of strategic surfaces, force systems, stability, comfort level, volume control, force distribution, ease of donning/doffing, trim lines, function of the prosthesis/orthosis, width/depth/height/length of prosthesis and/or orthosis, suspension and strap location(s).

Comparison of affected segment to non-affected segment and/or norms, measure deviation from normal posture. Evaluation may include: changes in tone, anatomical relationships and joint stability in frontal, sagittal, and transverse planes.

Effectiveness of positioning for ADL / functional activities / respiratory function, and skin tolerance to corrected position.

Prosthetics: prosthetic length, socket length, and static alignment. This may include the assessment of the socket mounted on a support stand to simulate weight bearing through the socket.

5 Dynamic Functional Evaluation (with prosthesis/orthosis) Evaluation of the entire body position, posture, support, comfort level and alignment of a prosthesis and/or orthosis in dynamic conditions.

Comparison of treated condition to untreated condition.

Evaluate intimacy of strategic surfaces, force systems, body segment volume control, width/depth/height/length trim lines and function of the prosthesis/orthosis.

Evaluation may also include: changes in tone, anatomical relationships and/or joints under dynamic conditions, dynamic balance, quality of suspension, and load-bearing characteristics, stability of tissue within prosthesis/orthosis, tri-planar joint motion, gait deviations, movement symmetry, mobility in frontal, sagittal, and transverse planes, ensure optimal biomechanical control, straps/pads placement, suspension and tri-planar positioning of mechanical joints, and footwear.  Use of gait aids or demonstration of ADL’s.

Evaluation of patient’s / caregiver’s ability to transfer/position in seating system, independence for donning and doffing the prosthesis/orthosis.

Prosthetics: Socket and prosthesis function while moving.  May include, in addition to previous assessments: quality of suspension, socket pistoning, pressure point, torque, socket stability, and tissue control.

6 Treatment outcome measures Using selected outcome measures and administered rating scale, compare baseline and final rating.

Quantify patient’s health and functional status using the World Health Organization’s International Classification of Function (ICF) based global rating of patient presentation and functional status. This rating identifies a goal-specific activity and evaluates how it creates a limitation or participation restriction.

The evaluation can span the following scales: pain, functional mobility, alignment, transfers, skin function, upper extremity, ADL, recreation/community or leisure activities, adaptive technology and distress/patient’s overall well-being.

The comparison of this rating before and after treatment will reflect an outcome measure. This is done pre and post treatment.

 

7 Review professional reports Review patient chart, documented reports, test results, treatments, referrals and ongoing treatment plans of other medical professionals

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