Documenting Activities Flashcards
Patient-Specific Orders
- Restrictions/Precautions
- Weight bearing status
- Activity Orders
Gather these in the medical chart review; If you don’t know and don’t have access ask the patient for information then ask their physician.
Restrictions
- Setting dependent restrictions
– Visitors (Number limit or covid)
– Monitoring devices (Don’t detach unless allowed) - Post-surgical restrictions
– Related to drains/tubes
– Positioning (THA)
Infectious Disease Precautions
Require additional PPE and treatment setting considerations:
– Contact
– Droplet
– Airborne
With precaution may not be able to go to specific places in a hospital.
Contact precaution
patient has a condition that is transmitted by direct contact with a person or items in their environment (C-Diff, draining wounds)
Droplet precautions
patient has a condition transmitted by large particle droplets of sputum or mucus (strep throat, whooping cough, flu)
Aireborne precautions
patient has a conditiontransmttedthrough the air (TB, COVID, SARS)
Weight Bearing Restrictions
- variation in interpretation of Lower Extremity and sometimes upper extremity
- based on patients BW that should be transmitted through limb
- Cannot use documentation to describe gait
Non-weight Bearing (NWBing)
- Foot does not touch the ground
- Upper extremity cannot be used for support
Toe-touch Weight Bearing (TTWBing)
Foot contacts ground for balance only
Only up to 20% of body weight
Partial Weight Bearing (PWBing)
Designated as 20-50% of body weight
Weight Bearing As Tolerated (WBAT)
Limited ONLY by patient tolerance (usually 50-100%)
Full Weight Bearing (FWBing)
No restriction / 100% WBing
Give an example of Weight Bearing
NO “patient is WBAT, when walking, demonstratesTTWBing”
YES “orders for WBAT on B LEs; noted when patient was participating in transfers / ambulating, put decreased weight through R LE during stance; patient indicates this is due to increased R knee pain to 7/10 in stance”
Activity Orders and Progressions
- Bedrest (strict – not out of bed for any reason)
- Bedrest with Bathroom Privileges / Commode Privileges
- Dangle at Edge of Bed (may be specific with durations)
- Up to Chair (may be specific with durations)
- Activity as Tolerated (no restrictions, but must be supervised / may require assistance for mobility)
- Up Ad Lib (no restrictions, can walk freely about the room and unit)
Elements of Documentation
- Clear and defensible
- Needs to reflect all relevant aspects of the patient encounter in a way that can be understood by all members involved in the patient’s care and can be reproduced by other professionals
- Needs to be timely (Same day)