New LMN

Updated by Dawn Garand

The LMN template is given below.  The <> symbol in the template is filled with the data described inside the <> symbol. 

MOBILITY EQUIPMENT ASSESSMENT

PATIENT:

<patient name>

DOB:

<patient date of birth>

Height:

<patient height in ft. and inch.>

WEIGHT:

<patient weight in lbs.>

DATE:

<ICD10 Code>

<ICD10 Description>

ICD10 rows repeated for each ICD10 on the order.

I. SUBJECTIVE INFORMATION

<patient name> is a <patient age> year old who was referred for assessment of <his/her> mobility and posture deficits. <patient name> presents today for consultation by a certified equipment specialist with regard to <his/her> request for new mobility related equipment. <patient name> reports medical history that is significant for mobility related ADL deficits. <He/She> is affected by physical limitations secondary to <his/her> medical diagnosis and demonstrates limitations in physical ability to ambulate. <He/She> is unable to complete MRADL's without adaptive equipment. <He/She> was put in contact with my company to obtain this consultation for new mobility related equipment. <patient name> reports that <he/she> is unable to complete mobility related activities of daily living secondary to <his/her> mobility impairment.

II. RECOMMENDATIONS

A. Based on the findings of this assessment, <patient name> 's medical condition has resulted in a need to receive adaptive equipment as recommended. This device as specified was found to be most appropriate, reasonable and accessible to meet <his/her> needs. It is reasonable to conclude that the equipment as recommended will maximize potential to normalize and improve <his/her> medical condition.

Item

Reason

<item description>

<item justifications>

Rows are repeated for each line item in the order.

B. EXPECTED LENGTH OF NEED: Lifetime

III. EXPECTED OUTCOME

Lower level equipment is not appropriate for due to the physical barrier that would result in limits for performing MRADL's efficiently, effectively or within a reasonable time frame. As a person who is dependent on adaptive equipment for mobility, <he/she> requires a device that promotes healthy posture and pressure management. will spend a majority of the day positioned in the recommended wheelchair. There are no less costly alternatives that provide <him/her> with the opportunity to achieve independence goals. 's height and weight are within the manufacturer's specifications for safe use of this device.

Signature

Date

<RTS name and title>

cc: <therapist name and title>

cc: <physician name and title>

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