Independent Living Inc. Pediatric Therapy Tampa FL



396240-476250Phone (813) 963-6923 Fax (813) 200-8659SPEECH & LANGUAGE THERAPYPROGRESS SUMMARY & PLAN OF CARE (if applicable)Patient: PCP: DOB: Facility: Parents: Address: Phone: Chronological Age: Phone: Adjusted Age (if appropriate): Fax: Date of Progress Summary: CC: Therapist: Medicaid #: CURRENT SPEECH/ LANGUAGE/FEEDING DIAGNOSIS(Listed in order of primary concerns)Choose an item/delete if not usingChoose an item/delete if not usingChoose an item/delete if not usingPROGRESS SUMMARY/STATUS CHANGE(Statement of effectiveness of therapeutic intervention)Click here to enter text.PROGRESS ON PREVIOUS LONG/SHORT TERM GOALS/PLAN OF CARE FORMCHECKBOX See attachedATTENDANCE/ PARTICIPATIONAttendance during previous authorization period was: FORMCHECKBOX Good (>80%) FORMCHECKBOX Fair (60-80%) FORMCHECKBOX Poor (<60%) If Fair or Poor, explain: FORMCHECKBOX Unable to document /data not available. Why: Patient participation/compliance during treatment sessions: FORMCHECKBOX Excellent FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX PoorDescribe: Click here to enter text.CAREGIVER TRAINING PROGRAMDescription of home program/caregiver training program implemented during previous authorization period: Click here to enter text.Adherence to caregiver training/ home exercise plan: FORMCHECKBOX Excellent FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX PoorExplain: Click here to enter text.Skilled therapy services continue to be indicated to carryout plan of care because: Click here to enter text.UPDATED THERAPEUTIC PROGNOSIS FORMCHECKBOX Excellent FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX PoorGiven (mark all that apply): FORMCHECKBOX Responsiveness to therapeutic techniques FORMCHECKBOX Attendance and participation in therapy sessions FORMCHECKBOX Follow through with caregiver training program/ home exercise program FORMCHECKBOX Stable medical status FORMCHECKBOX Met optimal functional potential FORMCHECKBOX Unstable medical condition FORMCHECKBOX Other: Comments: RECOMMENDATIONSRecommendations are as follows: FORMCHECKBOX Continue with Speech Therapy: as skilled services are necessary to carryout POC because it requires one-on-one instruction from a skilled therapist due to the need for continually updated goals and techniques that cannot be provided by this patient’s caregiver at home. Patient and caregiver will follow-up with a home program that is designed to aid in appropriate carryover. FORMCHECKBOX See Attached for Plan of Care (POC) FORMCHECKBOX Continued therapy is not recommended at this time; no POC required. FORMCHECKBOX Due to change in rehabilitative potential transition to consultative services/home maintenance program recommended. FORMCHECKBOX Therapy is not indicated at this time but a Re-Evaluation is recommended in 6 months; no POC required. FORMCHECKBOX Refer to: FORMCHECKBOX Physician for consideration of: FORMCHECKBOX Developmental Pediatrician and/or Neurology FORMCHECKBOX Behavioral and/or Psychological Intervention Services. FORMCHECKBOX Audiologist for: FORMCHECKBOX Occupational Therapy FORMCHECKBOX Physical Therapy FORMCHECKBOX Other: If you have any questions or concerns regarding this evaluation, please call Independent Living, Inc.- Pediatrics at (813) 963-6923 or fax us at (813) 200-8659._______________________________________________________________________Therapist SignatureDate:FL License #: __________________________________________________________________________Supervisor Signature (if appropriate)DateFL License #: ................
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