Page 141 - Business Development Orientation Binder

SUPPORTING HOMEBOUND STATUS

FUNCTIONAL COGNITIVE! BEHAVIOR MEDICAL/CLINICAL MD ORDERED TREATMENTS
SOB with minimal exertion - Severe dementia - needs Open, large, draining wounds No weight bearing/partial
e.g., talking, eating, at rest constant supervision (name location[s]) - will worsen weight bearing( Right or Left)
(NAME the activity leading to with movement due to e.g.
the SOB) • Diabetic foot ulcer
• Total hip replacement
• Total knee replacement-
Frequently forgetful/confused -
SOB with moderate exertion— Pain -- due to e.g., Limited activity (NAME the
unable to travel independently
e.g., transferring, dressing, • Angina limitation e.g. bedrest with
using the commode, and • PVD BRP)
walking less than 20 ft. (NAME • Arterial ulcers
the activity causing the SOB.) • Diabetic neuropathy
Fatigue with minimal exertion - • Advanced cancer Depressed immune system -
e.g., talking, eating (NAME the • Surgery reverse isolation
activity leading to the fatigue) ... exacerbated by movement
Fatigue with moderate exertion Severe edema (specify location)
- e.g., transferring, dressing, - which limits movement
using the commode, walking
less than 20 ft (NAME the
activity leading to the fatigue.)
Transfers with assistive device
AND 1 person assist
OR
Transfers with 1-2 person
assist
Ambulates with assistive device
AND 1 person assist
OR
Ambulates with 1-2 person
assist