Wheeled Mobility and Seating Evaluation
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Wheeled Mobility and Seating Evaluation To be completed by Physiatrist, Physical Therapist or Occupational Therapist PATIENT INFORMATION Name DOB Sex Date Address Physician Phone MD NPI # MD Phone Therapist Spouse/Parent/Caregiver name 1º Insurance/Payor Contact Person Phone number Policy # 2º Insurance/Payor Phone This evaluation / justification form will serve as the LMN for the following supplier Policy # Reason for Referral Patient Goals Caregiver Goals Specific Mobility Limitations that May Affect Care MEDICAL HISTORY Diagnosis ICD9 Code ICD9 Code Progressive Disease Height 1o Dx Onset Diagnosis ICD9 Code ICD9 Code Relevant Past and Future Surgeries Weight Explain Recent Changes or Trends in Weight Pertinent Medical Hx Cardiac Status Intact Impaired Respiratory Status Intact Orthotics Prosthetics Impaired Functional Limitations Severely Impaired NA Functional Limitations Severely Impaired O2 Time L / Min. Diagnosis Diagnosis Patient Name CURRENT SEATING / MOBILITY Current Mobility Base None Stroller Power Power w/ tilt Type of Control Manufacturer Serial # Additional Components Seat Height Condition of Current Mobility Base Problems with Current Mobility Base Manual w/c Manual with tilt Manual with recline Power w/ recline Power w/ tilt & recline w/ seat elevator Model Color Age Seat Width Seat Depth Current Seating System Scooter w/ stand Age of Seating System COMPONENT MANUFACTURER / CONDITION Seat Base Mounting Hardware Cushion Pelvic Support Thigh Support Knee Support Foot Support Foot Strap / Heel Loop Back Mounting Hardware Lateral Trunk Supports Chest / Shoulder Support Head Support Mounting Hardware UE Support Mounting Hardware Other Other When Relevant Overall Seat Height Describe Posture in Present Seating System Overall W/C Length Overall W/C Width CURRENT MRADL STATUS (with present Mobility Assistive Equipment) Indep Assist Unable Indep with Equip Not assessed Comments / Equipment Dressing Eating Grooming/Hygiene Toileting Bathing IADLS Bowel Mgmt Continent Incontinent Accidents Comments Bladder Mgmt Continent Incontinent Accidents Comments DESCRIBE WHAT HAS CHANGED TO REQUIRE NEW AND/OR DIFFERENT MOBILITY ASSISTIVE EQUIPMENT Page 2 of 13 Patient Name HOME ENVIRONMENT House Condo/Town Home Apartment Asst Living LTCF SNF Lives Alone / No Caregivers Lives Alone / Caregiver Asst Lives with Caregiver Comments Home is Accessible to Equipment Storage of Wheelchair In Home Stairs Yes No Ramp Yes No Own Hours Home Alone Rent Other Comments COMMUNITY ADL TRANSPORTATION Car Van Public Transportation Where is W/C Stored During Transport? Self Driver Drive While in Wheelchair Employment Specific requirements pertaining to mobility School Specific requirements pertaining to mobility Other Adapted W/C Lift Yes No Ambulance Other Tie Downs Passenger only Yes Sits in Wheelchair During Transport No STRENGTH / RANGE OF MOTION Gross Overall Strength Upper Extremity Lower Extremity Normal 5 / 5 Normal 5 / 5 Good 4 / 5 Good 4 / 5 Fair 3 / 5 Fair 3 / 5 Poor 2 / 5 Poor 2 / 5 Trace 1/ 5 Trace 1/ 5 No Movement No Movement Manual Muscle Test on file/noted on pages 6 & 7 Manual Muscle Test not on file Gross Range of Motion Shoulder Elbow Wrist Hand Hip Knee Ankle Goniometric Measurements on file/noted on page 6 & 7 Goniometric Measurements not on file Patient has sufficient strength and range of motion to ambulate and participate in MRADLs. Patient does not have sufficient strength and/or range of motion to ambulate and participate in MRADLs. Patient has sufficient strength and range of motion to propel a manual W/C and participate in MRADLs. Patient does not have sufficient strength and/or range of motion to propel a manual W/C and participate in MRADLs. Patient has sufficient strength and range of motion to operate a POV and participate in MRADLs. Patient does not have sufficient strength and/or range of motion to operate a POV and participate in MRADLs. Comments BALANCE Static Sitting Dynamic Sitting Static Standing Normal / WFL Normal / WFL Normal / WFL Good / Min Asst Good / Min Asst Good / Min Asst Fair / Mod Asst Fair / Mod Asst Fair / Mod Asst Poor / Max Asst Poor / Max Asst Poor / Max Asst Unable/Dependant Unable/Dependant Unable/Dependant Patient has sufficient balance to ambulate and participate in MRADLs. Patient does not have sufficient balance to ambulate and participate in MRADLs. Dynamic Standing Normal / WFL Good / Min Asst Fair / Mod Asst Poor / Max Asst Unable/Dependant Patient has sufficient balance to propel a manual W/C to participate in MRADLs. Patient does not have sufficient balance to propel a manual W/C to participate in MRADLs. Patient has sufficient balance and endurance to operate a POV and participate in MRADLs. Patient does not have sufficient balance and/or endurance to operate a POV and participate in MRADLs. Comments Page 3 of 13 Patient Name VISUAL / PERCEPTUAL and SENSORY PROCESSING SKILLS Comments Right Eye Intact Left Eye Intact Right Eye Impaired Left Eye Impaired Perceptual Perceptual Skills Intact Perceptual Skills Impaired Comments Motor Planning Intact Impaired N/A or NT Comments Handedness Right Left N/A Comments Patient has sufficient vision, perception and motor planning to operate MAE and participate in MRADLs. Patient does not have sufficient vision, perception and/or motor planning to safely operate MAE and participate in MRADLs. Comments Vision SENSATION and SKIN INTEGRITY Sensation Intact Impaired Absent Hyposensate Hypersensate Please describe Pressure Relief Able to perform effective pressure relief Method If not, Why? Skin Issues / Skin Integrity Current Skin Integrity Intact Red Area Open Area History of Skin Issues Yes Yes No No Hx of Skin Surgery Where Where When When Yes No Where Size Scar Tissue At Risk -Prolonged Sitting Limited Sitting Tolerance Hours per Day Yes No Braden Score, if administered Complaint of Pain 0 1 2 3 4 5 6 7 8 9 10 VERBAL COMMUNICATION WFL Receptive WFL Expressive Understandable Difficult to Understand Uses an Augmentative Communication Device Manufacturer/Model AAC Mount Needed Sign Non-communicative TRANSFERS and AMBULATION Transfers Independent Min Assist Mod Asst Max Asst Dependent Sliding Board Lift / Sling Required Ambulation Independent all Distances & Terrains Indep. Short Distance ( ft.) Indep. Smooth/Level Surfaces Indep. with Device ( ft.) Standby/Contact Asst w/ device w/o device Min Physical Asst w/ device w/o device Mod Physical Asst w/ device w/o device Max Physical Asst w/ device w/o device Unable to Ambulate Comments Timed Up and Go Test sec. [60-69 y 8.1sec (7.1-9.0), 70-79 y 9.2 sec (8.2-10.2), 70-99 y 11.3 sec (10.0-12.7)] EXPLAIN WHY PATIENT IS NON-AMBULATORY or NOT A FUNCTIONAL AMBULATOR Page 4 of 13 Patient Name WHEELCHAIR SKILLS (Shown by Trial) Indep Assist Dependent /Unable N/A Comments Manual W/C Propulsion Safe UE or LE strength and endurance is sufficient to Functional Distance Method participate in MRADLs using a manual wheelchair Left UE or LE strength and/or endurance is not sufficient to Arm Foot Left participate in MRADLs using a manual wheelchair Safe Functional Distance Operate Scooter Right Right Both Both Strength, hand grip, balance, control & transfers are appropriate for scooter use. Strength, hand grip, balance, control or transfers are not appropriate for scooter use. Living environment is appropriate for scooter use. Living environment is not appropriate for scooter use. Operate PWC w/ Joystick & Standard Programming Operate PWC w/ Joystick & Advanced Programming Operate PWC w/ Alternative Control Safe Functional Distance Safe Functional Distance Safe Functional Distance COMMENTS MAT EVALUATION A C F B G H I D J L K E M N O Measurements in Sitting A B C D E F G + + Shoulder Width Chest Width Chest Depth (Front – Back) Hip width Between Knees Top of Head Occiput Overall width (asymmetrical width for windswept legs or scoliotic posture Left Right H I J K L M N O Seat to Top of Shoulder Acromium Process (Tip of Shoulder) Inferior Angle of Scapula Seat to Iliac Crest Seat to Elbow Upper leg length Lower leg length Foot Length Page 5 of 13 Patient Name POSTURE COMMENTS Anterior / Posterior P E L V I S Posterior Non Reducible Partly Reducible Reducible TRUNK Neutral Obliquity Anterior Non Reducible Partly Reducible Reducible Anterior / Posterior WFL Thoracic Kyphosis Non Reducible Partly Reducible Reducible WFL R elev* *viewed from behind Other Rotation-Pelvis L elev* WFL Other Left / Right Lumbar Lordosis Convex Left c-curve s-curve Non Reducible Partly Reducible Reducible Other Position Left Anterior Non Reducible Other Partly Reducible Reducible Rotation-shoulders and upper trunk WFL Right Anterior Convex Right multiple Other Neutral Left-anterior Right-anterior Non Reducible Partly Reducible Reducible Other Windswept Hip ROM Limitations H I P S Neutral ABduct ADduct Non Reducible Dislocated Partly Reducible Subluxed Reducible Knee Position KNEES & FEET Neutral Right Non Reducible Partly Reducible Reducible Left Other Foot Position WFL L R WFL L R Limitations L R Limitations L R Dorsi-Flexed L R Non Reducible L R Non Reducible L R Plantar Flexed L R Partly Reducible L R Partly Reducible L R Inversion L R Reducible L RReducible L REversion L R DESCRIBE REFLEXES/TONAL INFLUENCE ON BODY Page 6 of 13 Patient Name POSTURE COMMENTS Functional HEAD & NECK Good Head control Flexed Extended Adequate Head Contol Rotated L Rotated R Limited Head Control Lat Flexed L Lat Flexed R Absent Head Control Describe Tone//Movement of Head and Neck Cervical Hyperextension U P P E R E X T R E M I Describe Tone/Movement of the Upper Extremities SHOULDERS Left Right Functional Elevated Depressed Protracted Functional Elevated Depressed Protracted Retracted Retracted Subluxed Subluxed Good UE movement/control Functional UE mvmt./control Limited UE movement/control Absent UE movement/control ELBOWS Left Right T Y & HAND Fisting Fisting Goals for Wheelchair Mobility Independence with mobility in the home with mobility related ADLs (MRADLs) Independence with community mobility Dependent mobility for safe transport Other – describe Goals for Seating System Optimize pressure distribution Provide support needed to facilitate function or safety Provide corrective forces to assist with maintaining or improving posture Accommodate client’s posture- Current seated postures and positions are not reducible or will not tolerate corrective forces Client to be independent with relieving pressure in the wheelchair Enhance physiological function such as breathing, swallowing, digestion and/or bowel/bladder elimination Other – describe EQUIPMENT TRIALS AND RESULTS Page 7 of 13 Patient Name MOBILITY BASE RECOMMENDATIONS and JUSTIFICATION MOBILITY BASE Manufacturer Model Color Seat Width Seat Depth Length of need Lightweight Manual Wheelchair High-strength Lightweight MWC Ultra-lightweight MWC Axle position adjustment vertical (dump) horizontal rotational (camber) Heavy-duty Manual Wheelchair Extra Heavy-duty MWC Scooter/POV Power Wheelchair JUSTIFICATION provide transport from point A to B promote independent mobility not a safe, functional ambulator walker or cane inadequate non-ambulatory self propulsion self propulsion full-time daily use improved UE access to wheels efficient propulsion Tilt Base or Tilt Feature Added Forward Rearward Powered tilt on power chair Powered tilt on manual chair Manual tilt on manual base Manual tilt on power base Recline Power recline on power base Power recline on manual base Manual recline on manual base Manual recline on power base Power Seat Elevator Power Standing Feature lifting requires features not available on a lightweight manual wheelchair increase chair stability change angle for improved postural stability user weight broken frame on previous chair extreme tone/excess movement has adequate trunk stability can safely operate & is willing to can safely transfer non-ambulatory non-functional ambulator cannot functionally propel manual wheelchair non-ambulatory non-functional ambulator cannot functionally propel manual wheelchair cannot functionally and safely operate scooter/POV home environment does not support the use of a POV can safely operate & is willing to can safely transfer Stroller Base width/depth necessary to accommodate anatomical measurement infant/child unable to propel manual wheelchair change position against gravitational force on head and shoulders change position for pressure redistribution/cannot weight shift accommodate femur to back angle bring to full recline for ADL care change position for pressure redistribution/cannot weight shift increase Indep in transfers increase Indep in ADLs requires speed adjustment requires torque adjustability requires sensitivity adjustability requires acceleration adjustability requires braking adjustability requires expandable electronics requires alternative drive control required to negotiate an incline of required to negotiate a rise of non-functional ambulator non-functional UE transfers management of tone rest periods control edema facilitate postural control rest periods repositioning for transfers or clothing/diaper/catheter management head positioning Page 8 of 13 Patient Name MOBILITY BASE COMPONENTS Armrests fixed adjustable height removable swing away flip back reclining full length desk length tubular Footrests/ Leg rests 60 70 80 90 heavy duty fixed lift off swing away elevating articulating elevating power elevating legrests power articulating elevating legrests Foot Platform flip up power elevating power articulating elevating Foot support flip up fixed/rigid adjustable angle R L multi-adjustable angle R L Drive/propulsion wheel size Wheel style mag spokes Wheel rims/ hand rims standard plastic coated other projections oblique vertical Drive/propulsion tires pneumatic semi-pneumatic flat free inserts solid Caster housing Caster size Style pneumatic semi-pneumatic flat free inserts solid Specific seat height Front Back Shock absorbers Spoke protector Side guards One armed drive attachment R Anti-tippers Amputee adapter Wheel locks push pull scissor Extension R L Transportation tie-down option Push handles extended angle adjustable standard Angle adjustable back Crutch/Cane holder Cylinder holder IV hanger Vent tray JUSTIFICATION provide support with elbow at 90 provide support for w/c tray change height/angle for ADLs remove for transfers allow to come closer to table top remove for access to tables provide LE support accommodate knee ROM elevate legs w/tilt and/or recline provide change in position for legs maintain feet on footplate manage tone/spasticity enable lateral transfers decrease edema physically unable to operate manual elevating legrests provide LE support accommodate hip abduction minimize turning radius maintain feet on footplate enable transfers provide foot support accommodate ankle ROM allow foot to go under w/c base elevate legs w/ tilt and/or recline change in position for legs decrease edema increase access to wheel allow seating system to fit on base increase propulsion ability maintenance free transfers increase self-propulsion with hand weakness/decreased grasp L decrease maintenance prevent frequent flats increase shock absorbency maneuverability stability of wheelchair increase shock absorbency durability maintenance foot propulsion transfers postural stability decrease vibration decrease pain protect hand/fingers from spokes prevent skin tears/abrasions enable propulsion of manual wheelchair with one arm prevent rearward displacement increase rearward stability indep in applying wheel locks provide crash tested brackets caregiver access caregiver assist postural control control of tone/spasticity accommodate range of motion decrease pain decrease spasms decrease pain decrease spasms allow feet under wheelchair base seat to floor height accommodation of leg length allows “hooking” to enable increased ability to perform ADLs, maintain balance or pressure relief UE functional control accommodate seating system Page 9 of 13 Patient Name MOBILITY BASE COMPONENTS POWER WHEELCHAIR CONTROLS Proportional JUSTIFICATION provides access for controlling wheelchair Type Body Part(s) Left Right Non-Proportional/switches Type Body Part(s) Upgraded/Expandable Electronics lacks motor control to operate proportional drive control unable to understand proportional controls programming for accurate control progressive disease/changing condition to operate power seat function(s) through drive control Display box to see which mode and drive the wheelchair is set necessary for alternate controls Digital Interface Electronics to allow the w/c to operate when using alternative drive controls Head Array to operate wheelchair through switches placed in tri-panel headrest Sip and puff w/ Tubing Kit needed to operate sip and puff drive controls Upgraded Tracking Electronics increase safety when driving correct tracking when on uneven surfaces Safety Reset Switches to change modes and stop the wheelchair when driving in latch mode Single or Multiple Actuator Control Module Mount for switches or joystick Attendant controlled joystick and mount Battery Charger Push rim active assist to operate the power seat function(s) through the drive control attaches switches to w/c swing away for safe transfers safety long distance driving operation of seat functions power motors on wheelchair charge battery for wheelchair enable propulsion of manual wheelchair on sloped terrain Other Other midline for optimal placement provides for consistent access compliance with transportation regulations enable propulsion of manual wheelchair for distance Page 10 of 13 Patient Name SEATING / POSITIONING COMPONENT RECOMMENDATIONS AND JUSTIFICATION Mfg/model/size COMPONENT JUSTIFICATION Seat cushion impaired sensation decubitus ulcers present history of decubitus ulcers increase pressure distribution commercially available cushion cannot accommodate deformity Seat cushionCustom Molded Seat wedge Cover replacement Mounting hardware lateral supports headrest medial thigh support back seat Seat board Seat platform Back board Back cushion Back cushionCustom Molded Lateral pelvic / thigh support Medial thigh support Foot support Foot box Shoe holder Ankle strap / heel loops Lateral trunk supports Anterior chest strap, vest, or shoulder retractors stabilize pelvis prevent pelvic extension accommodate obliquity/rotation accommodate multiple deformity neutralize LE fixed swing away accommodate ROM aggressive seat shape to decrease sliding down in the seat protect back or seat cushion attach seat platform/cushion attach back platform/cushion mount postural support(s) support cushion to prevent hammocking of upholstery swing-away for safe transfers flip-down/away for safe transfers multi-axis for accurate positioning & removal for safe transfers attach cushion/back to base accommodate seat to floor height provide posterior trunk support provide lumbar/sacral support provide posterior/lateral trunk support trunk in midline support pressure relief over spinous accommodate deformity processes accommodate or decrease tone facilitate tone commercially available back cannot accommodate deformity R R L L pelvis in neutral accommodate pelvis position upper legs decrease adduction accommodate ROM position foot accommodate deformity support foot on foot support decrease extraneous movement R L decrease lateral trunk leaning accommodate asymmetry contour for increased contact decrease forward movement of shoulder accommodation of TLSO decrease forward movement of trunk accommodate tone removable for transfers remove for transfers alignment stability decrease tone control position provide input to heel protect foot safety control of tone added abdominal support alignment assistance with shoulder control decrease shoulder elevation Page 11 of 13 Patient Name COMPONENT Mfg/model/size JUSTIFICATION Headrest provide posterior head support provide posterior neck support provide lateral head support provide anterior head support support during tilt and recline improve feeding improve respiration placement of switches safety accommodate ROM accommodate tone improve visual orientation Neck support decrease neck rotation decrease forward neck flexion Upper extremity support Arm trough ______Hand support ½ tray Full tray Swivel mount Pelvic positioner Single pull belt Specialized belt SubASIS bar /other Essential needs bag or pouch R L decrease edema decrease subluxation control tone provide work surface placement for AAC/Computer/EADL stabilize tone decrease falling out of chair prevent excessive rotation Holds medicines orthotics special food clothing changes decrease gravitational pull on shoulders provide midline positioning provide support for UE function provide hand support in natural position pad for protection over boney prominence prominence comfort special pull angle to control rotation diapers catheter/hygiene ostomy supplies Other Other Follow up / Plan of Care Page 12 of 13 Patient Name Patient/Caregiver Signature Date Therapist Name Printed Therapist’s Signature Date Supplier’s Name Printed Supplier’s Signature Date I agree with the above findings and recommendations of the therapist and supplier Physician’s Name Printed Physician’s Signature Date This is to certify that I, the above signed therapist have the following affiliations This DME Supplier Manufacturer of Recommended Equipment Patient’s Long Term Care Facility None of the above Page 13 of 13
