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Dhcs4505 CCS Medical Therapy Plan

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State of California—Health and Human Services Agency Department of Health Care Services
Medical Therapy Program
CCS MEDICAL THERAPY PLAN
PT OT Change from previous Rx
NOTE: Physician’s signature and therapist’s signature are required in order for CCS MTP services to be provided and to
signify an approved therapy plan.
Child’s name CCS number Date
Date of birth Treating diagnosis
Functional status (see page 2 for codes):
Mobility: __________________ Ambulation:_______________ Community skills: __________ Toileting: ________________
Dressing:_________________ Transfers: ________________ Home skills: ______________ Bathing: _________________
Feeding: _________________ Other: ___________________________________________________________________________
Treatment plan:
Gait training
Transfer training
Functional mobility
Therapeutic exercise
School program
Functional goals and objectives to meet the goals:
Functional ADLs
Community skills
Modalities
Splinting (UE/LE)
Home program
MTU conference
Monitor
Consultation
Evaluation
Discharge from MTP
Benefits of previous therapy
Rehab potential: Good Fair Limited
Frequency Duration Proposed date of initiation
Therapist’s signature Printed name
Medical therapy unit County
Physicians: Please review the above and indicate any changes or additions to the information provided and sign below.
Precautions
Physician’s signature Date Proposed date of medical
(re)evaluation
Original—File in MTU Case Record Photocopy 1—Send to Parent/Caregiver
Special Education Local Plan Area (SELPA)
Photocopy 2—Send to Local Educational Agency (LEA)
DHCS 4505 (09/07) Page 1 of 2
INSTRUCTIONS
Functional Status: Functional status is objective and measurable in order to demonstrate progress attained by the patient as
a result of therapy intervention in relation to ADLs and current level of function. General levels include:
• Independent (Ind): The child performs the entire activity in an appropriate amount of time without a helper, assistive device,
structured environment, or set-up.
• Modified Independent (ModI): The child performs the entire activity in an appropriate amount of time without a helper, but
requires one or more of the following:
• assistive device (including orthotic/prosthetic devices)
• structured environment
• set-up by therapist or helper
• Supervision (SUP): The child performs the entire activity in an appropriate amount of time but requires a therapist or helper
in the same room or general area to help stay on task or provide verbal cueing (including sequencing reminders).
• Stand-by Assist (SBA): The child performs the entire activity in an appropriate amount of time but requires therapist or
helper standing by, but not touching (usually for safety).
• Contact Guard Assist (CGA): The child performs approximately 100 percent of the physical effort but requires tactile
cueing or light hands by the therapist or helper.
• Minimal Assist (MIN): The child can perform most of the activity (approximately 75 percent), and the therapist or helper is
required to carry out only a small portion of the activity.
• Moderate Assist (MOD): The child and the therapist or helper each perform approximately 50 percent of the physical
effort.
• Maximum Assist (MAX): The child can assist in some part of the activity (approximately 25 percent), and the therapist or
helper is required to carry out most of the activity.
• Dependent (DEP): The child does not participate significantly in the activity and requires total assistance.
Treatment Plan: Must agree with the current written orders and be approved by the physician. Measurable functional goals,
which are expected to be achieved within the time frame of the prescription, must be included. Treatment
methods/interventions must be included as part of the plan. The goals must be based on the results of the therapy evaluation.
Functional Goals: Functional short-term goals should be established that will reflect anticipated progress to be made by the
child during the duration of the prescription. A functional goal should address an area of ADL or mobility including, but not
limited to: ambulation, transfers, specific self-care skills, and home and community accessibility. Functional goals promote a
maximum level of independence.
Objectives: Measurable Steps Towards the Goal.
Benefits of Previous Therapy: Documentation of objective, responses made by the child as a result of therapeutic
intervention.
Rehab Potential: Should be indicated as good, fair, or limited. Rehab potential is a statement of how well the patient will
respond to therapeutic input.
• Good: The child should respond well to the therapeutic intervention and will make significant progress toward the goal over
a set period of time.
• Fair: The child should respond satisfactorily to therapeutic intervention and may make steady progress toward the goals.
• Limited: The child is not expected to benefit from active therapy intervention, but may require periodic checks, monitoring,
or consultation to assess current function or needs.
Frequency: The number of treatments that a physical therapist or occupational therapist (per week/month/year) is required to
meet the stated goals.
Duration: The period of time that will accurately reflect the therapy needs of the child without modification. Children receiving
therapy at a rate of one time per week or greater must have the therapy plan and prescription reviewed every six months.
Children receiving therapy services less than once a week must have the therapy plan and prescription reviewed at least
annually.
Proposed Date of Initiation: The proposed date the prescribed therapy plan can commence.
Proposed Date of Medical (Re)Evaluation: The anticipated date the child must be seen again by the physician in order to
review/renew the therapy plan.
Change from Previous Prescription: If this is a new or a significant change in the child’s therapy plan, this area should be
checked.
DHCS 4505 (09/07) Page 2 of 2
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Completed 3 July 2020

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