4. Skilled Documentation Examples of Skilled PT Daily Note Documentation
97110: Therapist initiated BLE TherEx protocol to include weight resistance at 60% of maximum, using SciFit trainer and monitoring patient’s RPE to not exceed 4 based on cardiac precautions in place. Therapeutic rest break of 1 minute provided after 6 minutes of the15 minute exercise based on precautions. BP pre-treatment 125/78. BP post-treatment 130/80.
97530: Bed mobility training provided with (02) substantial/maximal assist and focus on proper sequencing and technique for supine<>sit. Therapist provided (02) assist with leg placement to initiate rolling to left and hand placement on bed rail to assist with rolling. Transfer training provided with (03) partial/moderate assist and instruction for upright posture and sequencing for lateral stepping towards sitting surface. Therapist instructed patient with seated tasks which engaged the abdominal musculature to improve sitting posture and develop trunk control for increased independence in unsupported sitting.
97112: Static standing balance training initiated for weight shifting for COG over BOS for improved balance to decrease fall risk with initiation of standing. Therapist facilitated bringing hips forward and increased trunk extension for upright upper body posture. Patient initially required (02) substantial/maximal assist for correction, therapist implemented use of mirror to enable selfcorrection, patient was able to reduce level of assistance needed to (03) partial/moderate assist with this visual feedback.
97116: Gait training provided 250x2 with RW (03) partial/moderate assist and instructions for correct sequencing with AD, improved weight shifting during transitional phase of gait, facilitation for symmetrical stance, and emphasis on increased stride length to normalize gait pattern with reduced risk of fall. Additional instruction provided for patient to safely navigate RW around obstacles to increase both hallway and in room safety.
97110: Therapist instructed patient in correct form and technique for BUE strengthening using 1# weight bar for shoulder flexion, abduction/adduction, bicep curls, tricep curls, and overhead shoulder press 3 x 10 reps with instruction fo proper upright posture and correct technique to maximize performance for improved self-positioning and functional transfers.
97530: Therapist instructed patient in grasp/release therapeutic activities with left hand to increase independence with dressing tasks and bed mobility. Facilitation was provided using hand over hand assistance due to muscle weakness. Treatment initiated with large items requiring full hand for grasp/release which patient demonstrated improved performance with but gradual decline with strength noted as size of items decreased. Unable to demonstrate performance of zippers, buttons, hooks, and snaps at this treatment.
97112: Therapist implemented use of PNF passive rhythmic rotation of the left shoulder to increase available range of motion for completion of dressing tasks. Pre-treatment range of shoulder flexion 60 degrees increased to 68 degrees post treatment. Pre-treatment range of shoulder abduction 90 degrees increased to 102 degrees post treatment.
97535: Therapist instructed patient with use of adaptive equipment for LB dressing including use of reacher and shoehorn with slip on loafer type shoes to compensate for patient’s decreased sitting balance and improve safety and independence with dressing. After demonstration of technique, patient was able to return demonstration of doffing/donning pants and shoes using both devices with (03) partial/moderate assist from therapist.
97760: Therapist provided initial fitting and patient education for application and positioning of left hand splint to decrease risk for contracture formation and maintaining functional ROM. Skin checks provided pre and post treatment with no significant changes in skin texture or color following a 2 hour wear time. Plan to increase wearing time an additional 2 hours every 2 days for tolerance of 8 hours.
97763: Orthotic follow-up for left hand splint that was adjusted for increase in ROM gained for increased finger extension. Skin check performed with no changes noted in texture or color. Wearing time has been extended to 6 hours per day with no complications.
92507: Therapist trained patient with use of large calendar book with journal entry areas to verbalize increased orientation to daily activities and decrease confusion/agitation. Patient was able to demonstrate ability to plan and enter activities on personal calendar with 70% accuracy. SLP presented patient with various font sizes and words vs phrases to increase patient use of visual aid. SLP used clinical judgment to use font size 16 with two word phrases.
92507: SLP provided open ended questions with Mod fading to Min verbal cues to develop communication of medical needs with staff. Patient demonstrates increased behaviors, with SLP determining use of decreased cues to reduce negative behaviors. Patient demonstrated ability to follow 2-step commands given verbal and visual cues with 60% to participate in daily activities.
97129/97130: SLP provided problem solving tasks directed to patient safety with patient able to produce accurate solution in 75% of attempts with minimal cues provided. Divergent task of providing 2-3 solutions per hazardous situation to increase safety. SLP addressed visual processing skills with ADL task cards to develop sequencing skills with patient requiring Mod A and completing with 40% accuracy; patient accuracy increased with 2 verbal options presented to 70%.
92526: SLP provided lingual coordination exercise using food 2x10 reps with moderate tactile and minimal verbal cues to improve bolus control and propulsion. Patient responded to cues with 75% ability. Patient performed mastication task 6/10 times with SLP placing food on left side. SLP provided therapeutic feeding with mech soft for possible upgrade to regular texture. Patient demonstrates moderate oral residuals, no coughing/throat clearing, no change in breathing pattern 70% of the time. SLP provided mod verbal and tactile cues to implement swallow strategy of alternate liquids reducing oral residuals to minimal amounts. Basic safe swallow strategies were demonstrated and reviewed by SLP x 2; max demonstration and instruction required for all strategies used to reduce risk of choking/aspiration with approx 30% of trials successful. SLP reviewed food preferences with patient to determine if any changes in diet/snacks offered would improve interest in intake/appetite. No significant changes made per pt. Interview.