Icf-template-web-2013.docx - University of Missouri



ICF (and Nagi) Template Pt. Name ______________, Group #____, Tutor Name _________________

PT 8390, Case Management II, Fall 2013

Directions: be sure to keep the same lettering for the categories, i.e. A, B, C …

Note: this is NOT a grading rubric. Refer to PCM Rubric in your syllabus for the details on what’s expected.

Point values for the various categories can be found on page ____ of the course syllabus (in the left hand margin).

A. PT Diagnosis ⋄ review the PCM Rubric for the details of the necessary requirements

B. Health Condition(s) ________________ (the equivalent Nagi term was Pathology)

● ICD-9(10) e.g. 820.8- Closed fracture of femoral neck

● Risk Factors for the pathology (don’t include the Consequences, just the Risk Factors)

● Comorbid conditions (remember: this is not the same as clinical features of the pathology)

● Differential Diagnosis ⋄ review the PCM Rubric for the details of the necessary requirements

● Assigned TASKS (if any), including G-code (initial eval only). *Other Stuff *

|C. (ICF) Body Structures (s) | Qualifier |

| | |

|List 2-3 codes with titles, and assign a Qualifier code (one decimal) |0 No limitation (0% to 4%, none) |

| |1 Mild limitation (5% to 24% slight) |

|e.g. s75012.2 Muscles of lower leg, moderate limitation (25% to 49%) |2 Moderate limitation (25% to 49%, medium) |

| |3 Severe limitation (50% to 95%, high) |

| |4 Complete limitation (95% to 100%, total) |

D. Impairments (Nagi) ⋄ review the PCM Rubric for the details of the necessary requirements

E. Functional Limitations (Nagi) ⋄ review the PCM Rubric for the details of the necessary requirements

|F. (ICF) Body Function (b) |Qualifier |

| | |

|List 2-3 codes and titles, and assign a Qualifier code (one decimal) |0 No limitation (0% to 4%, none) |

| |1 Mild limitation (5% to 24% slight) |

|e.g. b7301.2: power of muscles of one limb, moderate limitation (25% to 49%) |2 Moderate limitation (25% to 49%, medium) |

| |3 Severe limitation (50% to 95%, high) |

| |4 Complete limitation (95% to 100%, total) |

|G. (ICF) Activities & Participation (d) |Qualifiers: Performance/Capacity . _ _ _ _ |

| | |

|List 2-3 codes and titles |1st Q: Performance (home), usual |

|Assign a 4_decimal_code for the Performance/Capacity Qualifiers (see detailed |2nd Q: Capacity (clinic), no assist of person or device |

|example in syllabus p.____ ) |3rd Q: Capacity (clinic), assist of person or device |

| |4th Q: Performance (home), no assist of person or device |

H. LTG + nested STGs ⋄ review the PCM Rubric for the details of the necessary requirements

I. Prognosis: ⋄ review the PCM Rubric for the details of the necessary requirements

|J. (ICF) Environmental Factors: (e) (physical and social) |J. (ICF) Environmental Factors: (e) |

| | |

|List 2-3 codes and titles |(physical and social) Barriers or Facilitators |

|(Don’t worry about using qualifier/decimal codes) | |

|Categorize them as either Barriers or Facilitators | |

K. POC: Setting, Frequency, Duration ⋄ review the PCM Rubric for the details of the necessary requirements

L. Address relevant aspects of: reimbursement, finances, payment, Medicare A, Medicare B, Medicaid, private insurance, admission requirements and qualifications, skilled care options, available community services, etc.

Task: Explain these issues from both the patient/family point of view, and also from the clinician’s point of view.

State your conclusions. (see Tool Kit: Reimbursement/Documentation)

M. Coordination, Communication, Documentation

N. Patient/Client-Related Instruction

O. Procedural Intervention (with BOLDED in-text citation of EB sources, e.g. (Dite, 2006). Demonstrate PROGRESSION.

P. Termination of PT Services, for episode of care. ⋄ review the PCM Rubric for the details of the necessary requirements

Q. Bibliography (prefer APA). BOLD the full citation if you have an EB source for it.

R. TOEs

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