OPUS PI demo draft

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OPUS / PI demo draft
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Orthotics and Prosthetics
Below knee, molded sock, sach foot, endoskeletal
system, including soft cover and
finishing   Common ICD-9 codes include V4975
amputation, below knee
L5300
Impairment Category and description
OPUS
Tracking Survey
Optional items added
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services. When the term device is used in a
question, it is referring to the orthosis or
prosthesis you have received or will receive from
this clinic.
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Lower Extremity Functional Status

• Gathered at Intake, Status/Discharge, and Follow
  up

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What was the date of your injury, surgery, or
illness for which you are being treated today? If
you were born with the problem, please input
birth date.
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Please select any assistive devices that you use.
Full length crutch (axillary) Half length
crutches (lofstrand) Walker Wheelchair or
scooter One cane Two canes
Other
If Other please type in what type of device is
used.
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Please indicate your affected leg(s) for which
you are being treated today
Left leg Right leg Both legs
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How many hours a day do you currently wear your
device?
I do not currently wear a device
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Please indicate how easily you get into and out
of the tub or shower.
Very Easy Easy Slightly difficult Very
difficult Cannot perform activity
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Do you usually get into or out of the tub or
shower using or not using your device?
Using Not using
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Please indicate how easily you dress your lower
body.
Very Easy Easy Slightly difficult Very
difficult Cannot perform activity
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Do you usually dress your lower body using or not
using your device?
Using Not using
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Please indicate how easily you get on and off the
toilet.
Very Easy Easy Slightly difficult Very
difficult Cannot perform activity
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Do you usually get on and off the toilet using or
not using your device?
Using Not using
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Please indicate how easily you get up off the
floor.
Very Easy Easy Slightly difficult Very
difficult Cannot perform activity
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Do you usually get up from the floor using or not
using your device?
Using Not using
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Additional Questions (same format)

• Balance while standing
• Stand one half hour
• Pick up an object from floor while standing
• Get up from a chair
• Get into and out of a chair
• Walk indoors
• Walk outdoors on uneven ground
• Walk outdoors in bad weather (e.g. rain, snow,
  wind)

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Additional Questions (same format)

• Walk up to two hours
• Walk up steep ramp
• Get on and off escalator
• Climb one flight of stairs with rail
• Climb one flight of stairs without rail
• Run one block
• Carry a plate of food while walking
• Put on and off prosthesis or orthosis

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Health Related Quality of Life

• Gathered Status/Discharge and Follow up
• (not at intake)

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How much do you keep to yourself to avoid the
reactions of others to your use of a device?
Not at all Slightly Somewhat Quite a
bit Extremely
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To what extent are you insulted by the attitudes
of other people towards your physical condition
(reason you use a device)?
Not at all Slightly Somewhat Quite a
bit Extremely
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To what extent are you prevented from doing what
you would like to do because of social attitudes,
the law, or environmental barriers?
Not at all Slightly Somewhat Quite a
bit Extremely
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How much does pain interfere with your activities
(including both work outside the home and
household duties)?
Not at all Slightly Somewhat Quite a
bit Extremely
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To what extent do you accomplish less than you
would like because of your physical condition?
Not at all Slightly Somewhat Quite a
bit Extremely
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Additional Questions

• To what extent do you accomplish less than you
  would like because of emotional problems?
• How much does your physical condition restrict
  your ability to run errands?
• How much does your physical condition restrict
  your ability to pursue a hobby?
• How much does your physical condition restrict
  your ability to do chores?
• How much does your physical condition restrict
  your ability to do paid work?
• To what extent have you cut down on work or other
  activities because of your physical condition?
• To what extent have you cut down on work or other
  activities because of emotional problems?

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How often during the past week did you feel full
of life?
All of the time Most of the time Some of the
time A little of the time None of the time
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How often during the past week have you felt calm
and peaceful?
All of the time Most of the time Some of the
time A little of the time None of the time
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How often during the past week did you have a lot
of energy?
All of the time Most of the time Some of the
time A little of the time None of the time
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How often during the past week have you been
happy?
All of the time Most of the time Some of the
time A little of the time None of the time
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How often during the past week have you been very
nervous?
All of the time Most of the time Some of the
time A little of the time None of the time
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Additional Questions

• How often during the past week have you
• have you felt so down in the dumps that nothing
  could cheer you up?
• have you felt downhearted and depressed?
• did you feel worn out?
• were you easily bothered or upset?
• did you have difficulty concentrating or paying
  attention?

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Are you employed
Full time Part time Not employed
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In a typical week, how many hours do you
Work for money
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In a typical week, how many hours do you
  Cook, clean, and look after your
home
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In a typical week, how many hours do you
  Manage household bills and expenses
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In a typical week, how many hours do you
  Look after children or provide care for a loved
one
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In a typical week, how many hours do you
  Go to classes or participate in learning
activities
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In a typical week, how many hours do you
  Volunteer
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What is your households largest source of
income?  (Mark only one)
My employment Other household members
employment Social Security Disability
Insurance Long term disability
insurance Retirement income Investments and
savings Lawsuit settlement Inheritance Public
sources (Social Security Supplement, etc.)
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I am attending school
Full time Part time Not enrolled
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For the condition for which I am being treated
today, I am currently receiving care from
a Please select all that apply
Doctor Physical Therapist Occupational
Therapist
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FOTO FS MeasureLower Extremity CAT selected
because patients impairment involves the leg
below the kneeGathered at Intake, Status, and
Follow Up
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Do you usually walk 2 blocks using or not using
your device?
Using Not using
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Do you usually put on your shoes and socks using
or not using your device?
Using Not using
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Do you usually get in and out of a car using or
not using your device?
Using Not using
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Do you usually perform light activities around
your home using or not using your device?
Using Not using
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Do you walk between rooms using or not using your
device?
Using Not using
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Do you get in and out of the bath using or not
using your device?
Using Not using
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General Information gathered by PI

• Informational or risk-adjustment items

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Wording change needs approval
Are you taking prescription medication for the
condition for which you are receiving treatment?
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How many days ago did the condition for which you
are being treated begin?
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Transient Ischemic Attack
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Are you a US veteran?
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