MSH|^~\&|ITS|ARH|||201912121334||ORU^R01|4128364|D|2.3|||AL|NE
PID|1|FHATVIG0010817|AB00008232|AB8120|ITSTEST^BLACKIE||20060909|M||||||||||AB000465/19|9875093584
PV1|1|I
OBR|1|||||201912121331|20191212|201912121330||||||||||||PT|FH-BERG||||S||||||
OBX|1|TX|||          \H\NAME\N\:   ITSTEST,BLACKIE           
OBX|2|TX|||         \H\ACCT#\N\:   AB000465/19    \H\UNIT#\N\:  AB00008232     
OBX|3|TX|||         \H\ADM DT\N\:   03/09/19    \H\PHN\N\:  9875093584     
OBX|4|TX|||\H\Physical Therapy\N\         \H\LOC\N\:   AB-HHH    \H\RM/B\N\:  ABHHH-205-1     
OBX|5|TX|||\H\Berg Balance Scale\N\         \H\DOB\N\:   09/09/2006    \H\A/S\N\:  13 M     
OBX|6|TX|||         \H\REG CAT\N\:   AB.ACU           
OBX|7|TX|||         \H\ATT DR\N\:   Oedoc,Marytrain MD           
OBX|8|TX|||         \H\FAM DR\N\:   Oedoc,Marytrain MD           
OBX|9|TX|||\ZU\                                                                                                                                                                     \N\                       
OBX|10|TX|||\H\BERG BALANCE SCALE \N\  
OBX|11|TX|||\H\Date: \N\12/12/19  
OBX|12|TX|||\H\  1. Sitting to Standing: \N\1                
OBX|13|TX|||\H\  2. Standing Unsupported: \N\1                
OBX|14|TX|||\H\  3. Sitting Unsupported Feet on Floor: \N\1                
OBX|15|TX|||\H\  4. Standing to Sitting: \N\1                
OBX|16|TX|||\H\  5. Transfers: \N\1                
OBX|17|TX|||\H\  6. Standing Unsupported Eyes Closed: \N\1                
OBX|18|TX|||\H\  7. Standing Unsupported Feet Together: \N\1                
OBX|19|TX|||\H\  8. Reaching Forward Outstretched Arm: \N\1                
OBX|20|TX|||\H\  9. Pick Up Object From Floor: \N\1                
OBX|21|TX|||\H\10. Turning to Look Behind L/R Shoulder: \N\1                
OBX|22|TX|||\H\11. Turn 360 Degrees: \N\1                
OBX|23|TX|||\H\12. Count Step Touch Measured Stool: \N\1                
OBX|24|TX|||\H\13. Standing Unsupported One Foot Front: \N\1                
OBX|25|TX|||\H\14. Standing On One Leg: \N\1                
OBX|26|TX|||\H\______________________________________________________ \N\  
OBX|27|TX|||\H\TOTAL SCORE: \N\14  
OBX|28|TX|||\H\/ \N\56  
OBX|29|TX|||  
OBX|30|TX|||  
OBX|31|TX|||\H\Score Interpretation  
OBX|32|TX|||\ZHU\ 2  
OBX|33|TX|||  
OBX|34|TX|||\N\   0-20   Non-Functional Ambulation     <45     Increased Risk of Falls     
OBX|35|TX|||   
OBX|36|TX|||   20-47  Walker  47-49  Cane Outdoors  
OBX|37|TX|||   
OBX|38|TX|||   44-46  Cane Indoors  50-56  Normal Unlimited  
OBX|39|TX|||  
OBX|40|TX|||\H\NB\N\:  This scale is a strong indicator; however, a score of 56 does not necessarily indicate normal balance and further assessment may be required.  
OBX|41|TX|||  
OBX|42|TX|||\H\BERG BALANCE SCALE - LEGEND  
OBX|43|TX|||  
OBX|44|TX||| 3  
OBX|45|TX|||  
OBX|46|TX|||#1. SITTING TO STANDING #2. STANDING UNSUPPORTED  
OBX|47|TX|||  
OBX|48|TX|||\N\INSTRUCTION:  Please stand up. Try not to use your hands for support. INSTRUCTION: Stand for 2 minutes.\H\    
OBX|49|TX|||  
OBX|50|TX|||\N\  4   Able to stand with no hands and stabilize  
OBX|51|TX|||       independently  
OBX|52|TX|||  3   Able to stand independently using hands  
OBX|53|TX|||  2   Able to stand using hands after several attempts  
OBX|54|TX|||  1   Needs minimal assist to stand or to stabilize  
OBX|55|TX|||  0   Needs moderate to maximal assist to stand   4   Able to stand safely 2 minutes  
OBX|56|TX|||  3   Able to stand 2 minutes with supervision  
OBX|57|TX|||  2   Able to stand 30 seconds unsupported  
OBX|58|TX|||  1   Needs several tries to stand 30s unsupported  
OBX|59|TX|||  0   Unable to stand 30 seconds unassisted  
OBX|60|TX|||   
OBX|61|TX|||   
OBX|62|TX|||\H\#3. SITTING UNSUPPORTED FEET ON FLOOR #4. STANDING TO SITTING  
OBX|63|TX|||  
OBX|64|TX|||\N\INSTRUCTION:  Sit with arms folded for 2 minutes INSTRUCTION:  Please sit down.  
OBX|65|TX|||  
OBX|66|TX|||  4   Able to sit safely and securely 2 minutes  
OBX|67|TX|||  3   Able to sit 2 minutes with supervision  
OBX|68|TX|||  2   Able to sit 30 seconds  
OBX|69|TX|||  1   Able to sit 10 seconds  
OBX|70|TX|||  0   Unable to sit without support for 10 seconds   4   Sits safely with minimal use of hands  
OBX|71|TX|||  3   Controls descent by using hands  
OBX|72|TX|||  2   Uses back of legs against chair to control descent  
OBX|73|TX|||  1   Sits independently but has uncontrolled descent  
OBX|74|TX|||  0   Needs assistance to sit  
OBX|75|TX|||   
OBX|76|TX|||\H\#5. TRANSFERS #6. STANDING UNSUPPORTED WITH EYES CLOSED\N\    
OBX|77|TX|||  
OBX|78|TX|||INSTRUCTION:  Move from chair to bed and back again.  One way toward  a seat with armrests and one way toward a seat without armrests. INSTRUCTION:  Close your eyes and stand still for 10 seconds.  
OBX|79|TX|||  
OBX|80|TX|||  4   Able to transfer safely with minor use of hands  
OBX|81|TX|||  3   Able to transfer safely with definite need of hands  
OBX|82|TX|||  2   Able to t/f with verbal cueing and/or supervision  
OBX|83|TX|||  1   Needs one person to assist  
OBX|84|TX|||  0   Needs 2 people to assist or supervise to be safe   4   Able to stand 10 seconds safely  
OBX|85|TX|||  3   Able to stand 10 seconds with supervision  
OBX|86|TX|||  2   Able to stand 3 seconds  
OBX|87|TX|||  1   Unable to keep eyes closed 3s but stays standing  
OBX|88|TX|||  0   Needs help to keep from falling  
OBX|89|TX|||   
OBX|90|TX|||\H\#7. STANDING UNSUPPORTED WITH FEET TOGETHER #8. REACHING FORWARD WITH OUTSTRETCHED ARM  
OBX|91|TX|||  
OBX|92|TX|||\N\INSTRUCTION:  Place your feet together and stand without holding. INSTRUCTION:  Lift arm to 90 degrees. Stretch out your fingers and reach forward as far  as you can.  
OBX|93|TX|||  
OBX|94|TX|||  4   Able to place feet together independently and  
OBX|95|TX|||       stand 1 min safely  
OBX|96|TX|||  3   Able to place feet together independently and  
OBX|97|TX|||       stand 1 min with supervision  
OBX|98|TX|||  2   Able to place feet together but unable to hold 30s  
OBX|99|TX|||  1   Needs help to attain position but able to stand 15s  
OBX|100|TX|||       feet together  
OBX|101|TX|||  0   Needs help to attain position \T\ unable to hold 15s   4   Can reach forward confidently greater than  
OBX|102|TX|||       10 inches  
OBX|103|TX|||  3   Can reach forward greater than 5 inches  
OBX|104|TX|||       safely  
OBX|105|TX|||  2   Can reach forward > 2 inches safely  
OBX|106|TX|||  1   Reaches forward but needs supervision  
OBX|107|TX|||  0   Needs help to keep from falling  
OBX|108|TX|||   
OBX|109|TX|||\H\#9. PICK UP OBJECT FROM THE FLOOR #10. TURN TO LOOK BEHIND OVER LEFT/RIGHT SHOULDERS  
OBX|110|TX|||  
OBX|111|TX|||\N\INSTRUCTION: Pick up the shoe/slipper, which is in front of your feet. INSTRUCTION: Turn to look behind you over left shoulder.  Repeat to the right.  
OBX|112|TX|||  
OBX|113|TX|||  4   Able to pick up slipper safely and easily  
OBX|114|TX|||  3   Able to pick up slipper but needs supervision  
OBX|115|TX|||  2   Unable to pick up but reaches 1-2 inches from  
OBX|116|TX|||       slipper and keeps balance independently  
OBX|117|TX|||  1   Unable to p/u and needs supervision while trying  
OBX|118|TX|||  0   Unable to try/needs assist to keep from falling   4   Looks behind from both sides \T\ weight shifts well  
OBX|119|TX|||  3   Looks behind one side only, other side shows less  
OBX|120|TX|||       weight shift  
OBX|121|TX|||  2   Turns sideways only but maintains balance  
OBX|122|TX|||  1   Needs supervision when turning  
OBX|123|TX|||  0   Needs assist to keep from falling  
OBX|124|TX|||   
OBX|125|TX|||\H\#11. TURN 360 DEGREES #12. COUNT NUMBER OF TIMES STEP TOUCH MEASURED STOOL\N\    
OBX|126|TX|||  
OBX|127|TX|||INSTRUCTION: Turn completely around in a full circle. Pause.   Then turn a full circle in the other direction. INSTRUCTION: Place each foot alternately on stool (\R\17cm ht).  Continue until each foot has touched the stool 4 times.  
OBX|128|TX|||  
OBX|129|TX|||  4   Able to turn 360 degrees safely in less than 4  
OBX|130|TX|||       seconds each side  
OBX|131|TX|||  3   Able to turn 360 degrees safely one side only in  
OBX|132|TX|||       less than 4 seconds  
OBX|133|TX|||  2   Able to turn 360 degrees safely but slowly  
OBX|134|TX|||  1   Needs close supervision or verbal cueing  
OBX|135|TX|||  0   Needs assistance while turning   4   Able to stand independently and safely and  
OBX|136|TX|||       complete 8 steps within 20 seconds  
OBX|137|TX|||  3   Able to stand independently and complete 8 steps  
OBX|138|TX|||       in greater than 20 seconds  
OBX|139|TX|||  2   Able to complete 4 steps without aid with  
OBX|140|TX|||       supervision  
OBX|141|TX|||  1   Able to complete 2 steps - needs minimal assist  
OBX|142|TX|||  0   Needs assist to keep from falling/unable to try  
OBX|143|TX|||   
OBX|144|TX|||\H\#13. STANDING UNSUPPORTED ONE FOOT IN FRONT #14. STANDING ON ONE LEG  
OBX|145|TX|||  
OBX|146|TX|||\N\INSTRUCTION: Place one foot directly in front of the other.  If you cannot place your foot directly in front, try to step far enough ahead that the heel of forward foot is ahead of toes of other foot. INSTRUCTION: Stand on one leg as long as you 
OBX|147|TX|||can without holding.  
OBX|148|TX|||  
OBX|149|TX|||  4   Able to place foot in tandem independently and  
OBX|150|TX|||       hold 30 seconds  
OBX|151|TX|||  3   Able to place foot ahead of other independently  
OBX|152|TX|||       and hold 30s  
OBX|153|TX|||  2   Able to take small step independently \T\ hold 30s  
OBX|154|TX|||  1   Needs help to step but can hold 15 seconds  
OBX|155|TX|||  0   Loses balance while stepping or standing   4   Able to lift leg independently and hold for greater  
OBX|156|TX|||       than 10 seconds  
OBX|157|TX|||  3   Able to lift leg independently and hold 5-10s  
OBX|158|TX|||  2   Able to lift leg independently and hold for > 3sc  
OBX|159|TX|||  1   Tries to lift leg, unable to hold 3s but remains  
OBX|160|TX|||       standing independently  
OBX|161|TX|||  0   Unable to try or needs assist to prevent fall  
OBX|162|TX|||  
OBX|163|TX|||\H\  
OBX|164|TX|||Comments:\N\  [*]  
OBX|165|TX|||  
OBX|166|TX|||\H\Harjit Jassal, Physical Therapist  
OBX|167|TX|||\N\Date/Time:  \ZU\12/12/19\N\  \ZU\1330