Occupational Therapy Maintenance Program Nutrition/Diet O ------------------------------ ----------------------- ------------------ --------------------------------------------- Regular Diet O Special Diet Specify: __________ _________________ O NPO (may receive NG, GT or IV feedings at home) (22) Participant’s Individual Plan of Care (Additional Services) (must be consistent with information provided in this IPC) Treatments/ Participant Problem Interventions Frequency Discipline Specific CBAS (must include a (Include amount of Objective/Goal of Treatment/ ADDITIONAL measurable starting point) [e.g., 15 minutes] of Treatment/ Intervention SERVICES intervention, the Intervention (must include measurable duration of (Box 22) objectives/goals) (e.g., 2x per intervention [e.g., week) for 2 whether individual and/or group intervention, and any activities)
Occupational Therapy Maintenance Program Nutrition/Diet O Regular Diet O Special Diet Specify: __________ _________________ O NPO (may receive NG, GT or IV feedings at home) ------------------------------ ----------------------- ------------------ --------------------------------------------- (22) Participant’s Individual Plan of Care (Additional Services) (must be consistent with information provided in this IPC) CBAS ADDITIONAL SERVICES (Box 22) Participant Problem (must include a measurable starting point) Treatments/ Interventions (Include amount [e.g., 15 minutes] of intervention, the duration of intervention [e.g., for 2 whether individual and/or group intervention, and any activities) Frequency of Treatment/ Intervention (e.g., 2x per week) Discipline Specific Objective/Goal of Treatment/ Intervention (must include measurable objectives/goals)
CBAS_Individual_Plan_of_Care_(IPC).docx