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Run: Functional Limitation Reporting Documentation

Functional Limitation Reporting Documentation template for recording therapy-related functional status, severity, goals, and outcome measures in one structur...

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Submission and Encounter Details

Patient Identifier (required)

Use the internal medical record or encounter identifier. Do not enter a full SSN or other unnecessary PII.

Encounter Date (required)

Date the functional status was assessed.

Discipline (required)

Report Type (required)

Functional Limitation and Severity

Primary Functional Limitation (required)

Functional Limitation Description (required)

Briefly describe the observable limitation and how it affects daily function.

Severity Rating (required)

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 (required)

Functional Goal

Enter the measurable functional goal if one has been established.

Expected Outcome Timeframe

Outcome Measures and Progress

Baseline Functional Status (required)

Summarize the baseline functional status at the start of the episode or reporting period.

Current Functional Status (required)

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 (required)

Enter the name of the clinician completing this report.

Clinician Credentials (required)

Enter professional credentials or license designation.

Attestation (required)

Yes No N/A

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