Final Documentation things Flashcards
A
Pt. requires mod A with stair climbing activities
due to limited ROM in both knees
S
Pt reports inability to negotiate his stairs PTA
S
States his goal is to return to work ASAP
O
Pt received a hot pack to the low back for 15 min followed by soli tissue mobilization
What’s in the objective section?
- Choice can be based on “S”
- Tests and measure results
- Functional status
- Treatment interventions / events
- Education / exercises
A
Pt. is an excellent candidate for instruction in WC mobility
Types of notes
- Initial evaluation
- Daily note
- Progress / interim note
- Goal writing note
- FIM scores
P
Pt. will be seen BID for gait and transfer training
and LLE strengthening exercises
O
Strength: 4/5 proximally in B UE’s
P
Pt will be able to go from sit to stand independently within 10 days
O
Strength: R LE proximal strength 2/5
O
Pt able to recall 3/3 THR precautions
AROM
- Independently performed
- Contraindications
- Unstable fracture site
- Severe acute inflammation
- Medical instability
- Severe pain / joint swelling
- Benefits
- Maintain ROM
- Improve strength, endurance, & flexibility
- Increase local blood flow
- Increase sensory input
- Reduce effects of disuse
- Prevention of blood clots
O
Pt has a Stage l pressure ulcer on the superior potion of the sacrum
ROM rationale
- Prevent contractures
- Provide elongation of
- Muscles
- Ligaments
- Tendons
- Joint capsules
- Provide sensory stimulation
- Increase strength (A AA R ROM)
A
Pt is at increased risk for sacral pressure decubati due to poor bed mobility and sensation
A
Pt. is an excellent candidate for prosthetic
training with a free knee unit
A
Pt will benefit from work station evaluation to
improve sitting posture and minimize neck pain
What’s in the Plan section?
- Treatment plan
- Goals
- Discharge planning
- Referral
- Recommendations
- Equipment order
PROM
- Dependent for joint movement
- Severe weakness / paralysis
- Severe neurological impairment (coma)
- Around a healing fracture
- Painful conditions associated with AROM
- Importance for future functioning
- Limitation for strengthening / prevention of atrophy
P
Pt. will be independent in donning and doffing their prosthesis in 1 wk.
Reasons for documentation
- For reimbursement
- Communication with others
- Legal document
- Quality assurance
- Retrospective research
P
Will provide training in going from supine to sit
A
Safety in unsupported sitting is decreased due to trunk weakness
Types if Range of Motion
- Active
- Active –assistive
- Resistive
- Passive
O
Gait: Amb. with RW, WBAT on L LE for 125 ft. requiring CG
P
Pt. will receive pulsed US to the R ant shoulder
with 1.5 wts/cm2 and 1 MHZ, 50% duty cycle for
10 min
A
Pt will progress much more quickly when his WBing status is upgraded to WBAT
A
Practice pattem Musculoskeletal G: Impaired joint mobility, muscle perfonnance and ROM associated with fracture
P
Will educate the patient`s family on inspection ofthe foot integument
P
Pt. will be mod I with stair climbing using one rail and a SC for ten 6” steps within 2 wks.
A
Pt exhibits neck pain due to a forward head posture and poor set up of her work environment
AAROM
- Assistance with outside forces during voluntary contractions
- Pain
- Weakness
- Motor control deficits
- Abnormal muscle tone
- Types of assistance
- Manual
- Mechanical
- Gravity
O
Flexibility: R SLR to 40o
What’s in the Subjective section?
- Information from patient, family members, etc.
- Related to c/o
- Home set up
- Social support
- Equipment
- Goals
- Medical history / medications
O
Pt. received training in lateral transfers with a sliding board
O
. Pt requires min A to go from sit to stand
A
Practice pattern Integumentary C: Impaired integumentary integrity associated with partial thickness involvement and scar formation
O
Vitals: HR 83 / BP 132/85 / Sp02 97%
S
Pt c/o R knee pain while descending stairs
A
R shoulder impingement syndrome and pain
limits the pt. during overhead reaching activities
S
Pt states that he would like to be able to nm the NYC marathon
S
Pt. c/o L wrist pain
O
Requires min A to for static sitting balance
P
Pt will receive a wide based quad cane upon discharge
What’s in the assessment section?
- Clinical judgment based on “S” and “O”
- Usually related to function
- Rationale for interventions
- Patient classification in practice patterns
S
Pt reports that he will not have any stairs when going into his house
A
Pt. will require less assistance with lateral transfers as strength in B UE’s improves
P
. Pt will receive OPD therapy 3x’s a week for 3 weeks
S
Pt reports that home bathroom doorway is too narrow for WC use
P
Will instmct the patient in ace wrapping for their R residual limb
S
Reports increased LBP during prolonged sitting
S
States onset of weakness in both legs in July 2012
P
Pt. will receive a HEP for increasing R shoulder
AROM
O
ROM: L knee PROM increased to 5 to 85o
P
Pt. will be referred to brace clinic for
assessment of proper shoe wear
P
Pt. will receive a RW prior to D/C and will be
followed by the Hunter Home Care Agency for
further therapy
S
Pt. reports inability to go from sit to stand from low surfaces
