Fillable Mc2946 Patient Therapy Record

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Mc2946 Patient Therapy Record

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The Mc2946 Patient Therapy Record form is 1 page long and contains:

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File type: PDF

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State of California—Health and Human Services Agency Department of Health Care Services
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
(1)
I
ll (1)
I
ll
(A) Good
(A) Good
(A) Continue
38–52 minutes = 3 units
(2) Medical appointment (2) School cancelled
(B) Fair
(B) Fair
(B) Modify
53–67 minutes = 4 units
with another child (3) Parent cancelled
(C) Poor
(C) Poor
(C) Re-evaluate
(3) Meeting (4) Failed appointment
(1) MTU conference
(4) Other (5) Holiday
O—Direct/Indirect
(2) Private
(6) Other
(3) CCS special center
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
Physical Therapy
Occupational Therapy
Treatment diagnosis
Primary diagnosis
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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Mc2946 Patient Therapy Record

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Completed 3 July 2020

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