| RPT |
.| .| Barthel Index of Activities of Daily Living| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>|
DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | Barthel Index: <-Index->| The higher the score, the greater the degree of independence, range 0 to 100.| | Questions
and Answers| | 1. Bowels (preceding week):| <*Answer_5673*>| 2. Bladder (preceding week):| <*Answer_5674*>| 3. Grooming (preceding 24 - 48 hours):| <*Answer_5675*>| 4. Toilet use:|
<*Answer_5676*>| 5. Feeding:| <*Answer_5677*>| 6. Transfer:| <*Answer_5678*>| 7. Mobility:| <*Answer_5679*>| 8. Dressing:| <*Answer_5680*>| 9. Stairs:| <*Answer_5681*>| 10.
Bathing:| <*Answer_5682*>| | Copyright (c) 1965, Maryland State Medical Journal| | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for
diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~
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