Form Mc 2946 - Patient Therapy Record
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1Department of Health Care Services
State of California—Health and Human Services Agency
California Children’s Services
PATIENT THERAPY RECORD
1–15 minutes = 1 unit
“T”—Therapist not available:
“P”—Patient not available:
S—Patient cooperation was:
A—Response to treatment:
P—Plan:
16–37 minutes = 2 units
I
I
(A) Good
(A) Good
(A) Continue
(1)
ll
(1)
ll
38–52 minutes = 3 units
(B) Fair
(B) Fair
(B) Modify
(2) Medical appointment
(2) School cancelled
53–67 minutes = 4 units
(C) Poor
(C) Poor
(C) Re-evaluate
with another child
(3) Parent cancelled
(1) MTU conference
(3) Meeting
(4) Failed appointment
O—Direct/Indirect
(2) Private
(4) Other
(5) Holiday
(3) CCS special center
(6) Other
Month:
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Total
S.
O: Treatment
A
DIRECT
Evaluation
B
Case conference
C
Field visit
D
Mileage
E
Consultation
F
INDIRECT
Documentation
G
Other
H
A:
P:
Month:
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Total
S.
O: Treatment
A
DIRECT
Evaluation
B
Case conference
C
Field visit
D
Mileage
E
Consultation
F
INDIRECT
Documentation
G
Other
H
A:
P:
Month:
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Total
S.
O: Treatment
A
DIRECT
Evaluation
B
Case conference
C
Field visit
D
Mileage
E
Consultation
F
INDIRECT
Documentation
G
Other
H
A:
P:
Signature(s)
Date
Treatment diagnosis
Primary diagnosis
Physical Therapy
Occupational Therapy
Patient name
Date of birth
Social security number
MTU and county number
CCS number
Year
Quarter
Medical direction
County of legal residence
Therapy D/C
MC 2946 (09/07)
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