Functional Limitation Reporting Documentation

Document functional status, therapy goals, severity, and outcome reporting details for therapy claims and quality reporting.

Submission and Encounter Details

• Patient Identifier
  Use the internal medical record or encounter identifier. Do not enter a full SSN or other unnecessary PII.
• Encounter Date
  Date the functional status was assessed.
• Discipline
• Report Type

Functional Limitation and Severity

• Primary Functional Limitation
• Functional Limitation Description
  Briefly describe the observable limitation and how it affects daily function.
• Severity Rating
  Select the severity level that best reflects the current functional limitation.
• Severity Basis
  Select all sources used to determine severity.

Goals and Expected Outcome

• Goal Status
• Functional Goal
  Enter the measurable functional goal if one has been established.
• Expected Outcome Timeframe

Outcome Measures and Progress

• Baseline Functional Status
  Summarize the baseline functional status at the start of the episode or reporting period.
• Current Functional Status
  Summarize the current functional status and any observable change.
• Outcome Measure Name
  Enter the standardized measure used, if applicable.
• Outcome Measure Score
  Enter the score associated with the outcome measure.

Clinician Attestation and Submission

• Clinician Name
  Enter the name of the clinician completing this report.
• Clinician Credentials
  Enter professional credentials or license designation.
• Attestation