Tilt-in-Space Manual Wheelchair

Tilt-in-Space Manual Wheelchair (E1161)
Face-To-Face
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 tilt-in-space manual wheelchair.
  5. Copy of any history of the present condition (s) and past medical history that is relevant to mobility needs.
  6. A Tilt-in-Space Wheelchair Medical Records must include: The patient is severely disabled due to a neurological disease and unable to self-propel a manual wheelchair or operate a power wheelchair. In the wheelchair most of the day requiring frequent repositioning.
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.

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 neurological diagnosis of (CP, MS-MD-Post Polo-Stroke) 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 spends most of the day in the wheel-chair requiring frequent repositioning. The patient’s functional mobility deficit can be sufficiently resolved safely by the use of a tilt-in-space wheelchair.