Physician Progress Note (Page 2 of 4) in pdf

These ADL issues cannot be resolved by a cane or a walker. The home is wheelchair accessible and the

wheelchair will improve their ability to perform toileting, feeding, dressing, grooming, bathing (MRADL’s).

Patient name is willing and able to use a wheelchair and weighs more than 250 lbs.

Extra Heavy Duty (>=300lbs)

I evaluated (patient name) face to face for durable medical equipment. He/She needs an extra heavy duty

wheelchair because of mobility limitations impairing their ability to participate in toileting, feeding, dressing,

grooming, bathing (MRADL’s) as noted in PT notes on Date and I concure with those PT notes.

Ex: unsteady gate due to weakness or neuropathy

Ex: Likely to fall because of distance to restroom, kitchen, etc

These ADL issues cannot be resolved by a cane or a walker. The home is wheelchair accessible and the

wheelchair will improve their ability to perform toileting, feeding, dressing, grooming, bathing (MRADL’s).

Patient name is willing and able to use a wheelchair and weighs more than 300 lbs.

High Strength Light Weight Wheelchair

I evaluated (patient name) face to face for durable medical equipment. He/She needs a high strength light

weight wheelchair because of mobility limitations impairing their ability to participate in toileting, feeding,

dressing, grooming, bathing (MRADL’s) as noted in PT notes on Date and I concure with those PT notes.

Ex: unsteady gate due to weakness or neuropathy

Ex: Likely to fall because of distance to restroom, kitchen, etc

These ADL issues cannot be resolved by a cane or a walker. The home is wheelchair accessible and the

wheelchair will improve their ability to perform toileting, feeding, dressing, grooming, bathing (MRADL’s).

Patient name is willing and able to use a wheelchair. Patient self-propels in the wheelchair while engaging in

frequent activities that cannot be performed in a standard or lightweight wheelchair. The patient spends

extended time in the wheelchair OR there is concern about the durability of the other wheelchair models.

Home Oxygen Equipment

I evaluated my patient face to face for durable medical equipment. The patient needs home oxygen

concentrator with portable oxygen with contents. Room air saturation level is % at rest, under exertion

% , with O2 at

LPM at exertion

% . Note: If patient at rest O2 levels are <=87%, no exertion test is

required.

For nocturnal oxygen: while awake RA says >89% and falls to <88% for more than 5 minutes while sleeping.

Enteral Feedings

I evaluated my patient face to face for durable medical equipment. The patient needs equipment for enteral

feedings because of dysphasia. Patient will have an impairment for a minimum of 3 months. Patient will need

equipment and formula for (LON at least 3 months up to 99 mos). Patients nutrition will be provided via a tube

into their stomach to maintain their weight and strength. A pump is required due to ___________ (severe

diarrhea, or dumping syndrome, or admission rate is <100ml/hr, or blood glucose changes, or circulatory

overload)

CPAP (f2f date must be before sleep test date to assess patients OSA)

I evaluated my patient face to face for durable medical equipment. The patient needs equipment for sleep

deprivation due to HTN, CVA, sleepiness, impaired cognition, or insomnia. Patients sleep test meets AHI or

RDI > 15 events per hour with a minimum of 30 events OR

Patients sleep test meets AHI or RDI > 5 and < to 14 events per hour with a minimum of 10 events And with

HTN, CVA sleepiness, imparted cognition, or insomnia.

Low air loss mattress

I evaluated my patient face to face for durable medical equipment. The patient needs a low air loss mattress due

to 2 or more stage II pressure ulcers or 1 or more stage III or stage IV pressure ulcer(s) located on the trunk or

Physician Progress Note Page 2

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