Name of the Procedure:

Self-care Functional Limitation

Common Name(s): Self-care Assessment, Functional Limitation Reporting
Technical or Medical Terms: HCPCS Code G8988

Summary

This procedure involves evaluating a patient's ability to perform self-care activities such as dressing, bathing, and grooming. It is used to set projected goals for the patient at the start of therapy, monitor progress at intervals, and assess outcomes at the end of the therapy episode.

Purpose

The assessment aims to determine the level of functional limitation a patient faces in performing everyday self-care activities. It helps tailor therapeutic interventions to improve independence and quality of life.

Indications

• Patients with disabilities or impairments due to medical conditions like stroke, arthritis, or injury.
• Individuals requiring occupational or physical therapy.
• Patients who are about to begin a rehabilitation program.

Preparation

• The patient may need to fill out a self-assessment form detailing current difficulties in self-care tasks.
• No special preparations are needed, but a review of medical history and current medication may be required.

Procedure Description

1. Initial Assessment: A healthcare professional evaluates the patient's current self-care abilities through observations and questionnaires.
2. Goal Setting: Based on the initial evaluation, therapeutic goals are set.
3. Interim Assessments: Progress is monitored at regular intervals using standardized tools and updated questionnaires.
4. Final Assessment: At the end of the therapy episode, a comprehensive evaluation is conducted to determine improvements and remaining limitations.

Tools and Technology:

• Standardized assessment forms
• Functional assessment tools (e.g., Functional Independence Measure)

Anesthesia or Sedation: Not applicable.

Duration

Each assessment session typically lasts between 30 minutes to an hour, depending on the complexity of the patient's condition.

Setting

This procedure is usually performed in outpatient rehab clinics, hospitals, and occasionally in home health settings.

Personnel

• Occupational Therapists
• Physical Therapists
• Rehabilitation Nurses

Risks and Complications

• Minimal risks, primarily related to patient discomfort or frustration during assessments.
• Rarely, the assessment may trigger emotional distress if the patient feels overwhelmed by their limitations.

Benefits

• Improved ability to perform daily self-care activities.
• Enhanced independence and quality of life.
• Better-targeted therapeutic interventions.

Recovery

• No physical recovery needed as the assessment itself is non-invasive.
• Regular follow-up sessions to reassess and adjust goals.
• Patients might have to follow specific exercises or therapy plans based on the assessment results.

Alternatives

• Functional Mobility Assessments: Focuses more on how the patient moves rather than self-care tasks.
• Comprehensive Geriatric Assessment: A broader evaluation that includes physical, social, and psychological aspects.

Pros and Cons:

• Functional Mobility Assessments are useful but lack the focus on self-care tasks.
• Comprehensive Geriatric Assessments offer a holistic view but are more time-consuming and can be overwhelming.

Patient Experience

Patients might feel a mix of emotions from recognition of their limitations to encouragement from setting achievable goals. To manage discomfort, therapists employ various motivational and supportive techniques. Pain management strategies are not typically required since the procedure is non-invasive.