Standard Manual Hemi-Wheelchair

Standard Manual Hemi-Wheelchair (K0002)
Partnership Documentation Checklist

Medical Records (Documented in the patient’s chart.)

  1. What is the patient’s mobility limitation and how does it interfere with the performance of activities of daily living?
  2. Why can’t a cane or walker meet this patient’s mobility needs in the home?
  3. Does this patient have the physical and mental abilities to operate a wheelchair safely in the home?
  4. Patient’s functional mobility deficit can be sufficiently resolved by the use of a hemi-manual wheelchair.
  5. Copy of any history of the present condition (s) and past medical history that is relevant to mobility needs.
  6. A Standard Hemi-Wheelchair Medical Records must include: Support that the patient requiring a lower seat height (17”-18”) because: short stature or need to place feet on ground for propulsion.
Detailed Written Order (Provided by supplier.)
  1. Beneficiary name.
  2. Detailed description of the item (s) to be provided.
  3. Treating physician’s signature and date order signed.
  4. Start date of order (if the start date is different than the signature date).

Sample Medical Records (Report of the face-to-face mobility examination.)
The face-to-face mobility examination was performed on (John Smith - March 1, 2011). A physical examination was performed relevant to the patients mobility needs, his diagnosis of (osteoarthritis, generative joint disease, coronary artery disease and COPD) severely impair the patient’s ability to ambulate and interferes with the ability to perform activities of daily living in his home.

The patient does not have the (strength or balance) to use a cane or walker safely and does have sufficient upper extremity function to propel a standard hemi-wheelchair. A Hemi wheelchair is required to accommodate the patients (short stature and/or need for foot propulsion). The patient’s functional mobility deficit can be sufficiently resolved safely by the use of a standard hemi-wheelchair.