actively participates with skilled interventions. Pt's temperature at 97 degrees.
Patient's I c ADL/self-care tasks assessed to ensure safe return to home. Patient is mod I c all ADL/self-care tasks. (you can be as vague or specific as you want as far as LOF c ADLs here, the more specific the better) Verbal HSA completed c patient/caregiver, see report for full details. OT recommendations include- grab bars, elevated toilet seat to facilitate increased I c toileting and decrease risk for falls. (whatever else the patient needs/whatever you recommend). OT discussed recommendations with social worker to ensure agreeance c proper AE/services for patient to return home safely.
Verbal HSA completed with patient/caregiver, see report for full details. OT recommendations include- grab bars, elevated toilet, bedside commode, wheelchair, ramp and 24 hour services provided to seat to increased Independence with self-care task toileting. OT discussed recommendations with family and social worker to ensure agreeance with proper AE/services for patient to return home safely.
Care plan meeting with pt and multidisciplinary team to report on pt's progress with POC goals and discharged planning.
Clinician attended care plan meeting with interdisciplinary team to discuss progress with therapy and recommendation for possible discharge home. Family/patient verbal understanding of OT recommendations.
Skilled interventions focused on training in log rolling technique to increase independence in bed mobility tasks. Clinician provided Max A to roll from side to side and from side lying to supine to decrease risk of pressure sore and maintain skin integrity.
Passive stretches
Clinician provided passive stretches to B glenohumeral joint sagittal, frontal, and horizontal plane, elbows in sagittal plane and wrist in sagittal and frontal planes with prolong stretch at end range to decrease risk of contractures and increase ROM. Clinician provided passive stretches to B elbows to increase ROM and facilitate participation with daily activities.
Clinician provided passive stretches to R glenohumeral joint sagittal, frontal, and horizontal plane, elbows in sagittal plane and wrist in sagittal and frontal planes with prolong stretch at end range with joint compression to decrease risk of contractures, normalize tone and increase ROM.
Clinician provided passive stretches to B shoulder in all planes with prolong stretch at end range to decrease risk of contractures and increase ROM in order to facilitate participation with daily activities. Pt required HOH to complete task this date.
Clinician provided passive stretches to B shoulder in all planes, elbows and wrist with prolong stretch at end range to decrease risk of contractures and increase ROM.
Clinician provided joint mobilization of B MCP, DIP, PIP, and wrist to normalize tone and increase ROM in order to tolerate B hand carrot splint and assist with self-care task. Pt tolerance session with no signs of pain or discomfort.
Self-feeding
Skilled interventions to facilitate independence with Self Feeding abilities included self-feeding techniques and wheelchair seating & positioning activities during self-feeding. Pt able to scoop/stab food with utensil and bring to mouth at S/U while sitting upright in w/c this date.
Dressing
Pt educated on UB dressing techniques using one hand to thread BUE through sleeves with Mod tactile cues to guide LUE through sleeve followed by RUE and pull garment overhead and down to complete task at Mod A.
Pt educated on safety precautions during transitional movements to increase independence with UB dressing and promote safety. Pt training in UB dressing technique via visual/verbal/tactile cues to promote ADL independence. Pt required Max A to thread BUE through sleeve and pull garment overhead to complete task.
Pt educated in UB dressing techniques using gown to simulate shirt to pull shirt overhead with Max A in 3/3 trials to facilitate increase participation with daily activities.
Pt training in safety during transfers to carryover with toilet commode transfers. Pt required supervised A to transfer using standard walker. Pt required min verbal cues for proper hand/foot placement and leaning forward while pushing off bed to ease sit to stand and complete task.
Pt educated on safety during transitional movements including locking wheelchair breaks prior to transfers, use of grab bars during toileting task order to decrease fall risk and increase self-care functional assessment score to 28/42. Pt required min verbal cues to return demonstration of safety precautions during session.
Progress note ex.
Pt showed progress at a result of skilled interventions this reporting period. Pt increase FIST of 51/56 noted this reporting period. Pt also demonstrated increase Barthel score of 75/100. Pt is able to transfer from w/c to toilet at I using grab bars for support during toileting task. Pt showed Dynamometer R grip strength of 29.1 kg. Pt required S/U for LB dressing task to following safety precautions secondary to fall risk and impulsive behaviors. Pt demonstrate activity tolerance of 15 minutes before taking rest break during session.
Exercises
biceps, triceps, deltoids, latissimus dorsi, trapezius, pectoralis major/minor, core musculature,
Bilateral Upper Extremity therapeutic exercise, including shoulder extension, shoulder flexion, hand MCP flexion, elbow flexion, elbow extension and shoulder external rotation seated unsupported to enhance muscle strength in order to enable increased participation in self care tasks.
Pt progressed through manual passive range of motion exercises to RUE glenohumeral joint in sagittal, frontal, and horizontal plane to increase ROM to facilitate independence with UB dressing. Therapeutic exercises for shoulders, elbows and wrist and deltoids, biceps, triceps targeted facilitating strength, coordination and tolerance for UB dressing and toilet commode transfers.
RUE resistive exercises via shoulder flexion, elbow flexion/extension and manual passive range of motion exercises to LUE glenohumeral joint in sagittal, frontal, and horizontal plane to increase ROM to facilitate independence with UB dressing and functional transfers. Therapeutic exercises targeting deltoids, biceps, triceps to facilitating strength, coordination and tolerance for UB dressing and toilet commode transfers.
Pt progressed through manual passive range of motion exercises to BUE glenohumeral joint in sagittal, frontal, and horizontal plane, elbows in sagittal plane and wrist in sagittal and frontal planes with prolong stretch at end range to decrease risk of contractures and increase tolerance of BUE carrot splint
Ongoing calming verbal instructions throughout session
Pt completed reciprocal resistive exercises to increase UB dressing independence and increase R AROM needed for ADLs. Clinician provided verbal and visual cues for upright posture during session to maximize muscles contraction and facilitate muscle strength of deltoids, biceps and triceps.
Pt completed reciprocal resistive exercises to increase oral hygiene independence and increase L AROM, strength and coordination needed for ADLs. Clinician provided Mod verbal, tactile and visual cues for upright posture during session to maximize muscles contraction and facilitate muscle strength of deltoids, biceps and triceps. Family/caregiver (wife) educated on therapeutic exercises with using of thera-band with verbal understanding.
Clinician provided BUE resistive and aerobic exercises via shoulder flexion, elbow flexion/extension 3 sets of 10 targeting deltoids, biceps and triceps to facilitate muscle strength, power, coordination and cardio to increase participation with daily activities such as UB dressing, LB dressing and toilet hygiene task. Pt required Min verbal/visual cues to initiate task.
To isolate muscle groups
Clinician instructed patient in BUE resistive and aerobic exercises via shoulder flexion and elbow flexion/extension. Therapeutic exercises targeted deltoids, biceps and triceps to increase muscles strength, coordination of BUE and tolerance.
Pt complete BUE resistive and aerobic exercises via shoulder flexion, elbow flexion/extension targeting deltoids, biceps and triceps with grip flexion to increase intrinsic/extrinsic muscles of the B hands to safely dress UB and LB and assist with toilet commode transfers. Pt required Min rest breaks during session this date.
Ther Ex: therapeutic resistance exercises, closed chain kinetic exercises, bicep curls, tricep curls and therapeutic exercises for UE to facilitate independence in self care tasks. Self Care Mngmt: safety training during transitional movements, energy conservation during ADLs, bathing skill training, toileting skill training, dressing techniques, initiation cues to facilitate skill performance and techniques to increase safety for ADLs in sitting. Therapeutic Activities: gross motor coordination, crossing midline to facilitate independence in functional skill performance, bilateral integration, dynamic balance activities during sitting, dynamic balance activities while sitting and standing and placement of objects out of reach to increase dynamic skill performance, toilet transfer training, shower chair transfer training, safety awareness training and energy conservation technique training needed for ADL independence.
Ther Ex: therapeutic resistance exercises, closed chain kinetic exercises, bicep curls, triceps curls and therapeutic exercises for UE to facilitate independence in self care tasks. Self Care Mngmt: safety training during transitional movements, energy conservation during ADLs, bathing skill training, toileting skill training, dressing techniques, initiation cues to facilitate skill performance and techniques to increase safety for ADLs in sitting. Therapeutic Activities: gross motor coordination, crossing midline to facilitate independence in functional skill performance, bilateral integration, dynamic balance activities during sitting and placement of objects out of reach to increase dynamic skill performance, toilet transfer training, shower chair transfer training, safety awareness training and energy conservation technique training needed for ADL independence.
via restorator x 15 minutes targeting deltoids, biceps, triceps and intrinsic/extrinsic muscles of the hand to facilitate muscle strength, power, coordination and cardio to increase participation with daily activities such as UB dressing, LB dressing, toileting and oral hygiene.
Clinician provided BUE resistive and aerobic exercises via shoulder flexion, elbow flexion/extension, and grip strength 3 sets of 10 targeting deltoids, biceps, triceps and intrinsic/extrinsic muscles of the hand to facilitate muscle strength, power, coordination and cardio to increase participation with daily activities such as UB dressing, LB dressing, and bathing.
BUE resistive exercises including shoulder flexion, elbow flexion/extension, wrist flexion/extension and MCP flexion. Therapeutic exercises targeting deltoids, biceps, triceps and intrinsic/extrinsic muscles of the hands to facilitate independence with LB dressing and toilet commode transfers.
Clinician provided BUE resistive exercises via manual resistance in flexion/extension of shoulder, elbow, wrist and digits to promote deltoid, bicep, triceps and intrinsic/extrinsic muscles strength, coordination, and activity tolerance required for UB/LB dressing functional transfers and bathing task.
Clinician provided BUE aerobic exercises targeting deltoids, biceps, and triceps via thera-band in order to facilitate muscle strength, coordination, ROM and activity tolerance in order to increase independence with ADLs. Pt required Mod rest breaks between reps due to fatigue. Pt's o2 during session at 95%.
THERA-ACT 97530
Pt instructed on proper sit to stand techniques. 5 repetitions with SBA and min cues to hand/foot placement and increasing forward weight shift resulting in increased ease and safely and decrease assistance from caregivers.
Pt was given instruction with bed mobility to utilize log rolling techniques. Pt performed supine to sit at EOB and bed to wheelchair transfers with SBA and min cues for abdominal bracing to initiate task and proper hand/foot placement to increase safety with transfers.
Therapist facilitated Proprioceptive Neuromuscular Facilitation (PNF) contract, relax and hold techniques to patients bilateral BUE deltoids to increase strength, tolerance and coordination for carryover to functional tasks such as UB dressing and oral hygiene. Pt required 25% verbal and tactile cues for sequencing of tasks. Therapist directed pt in reaching outside base of support during unsupported/supported sitting activity to increase trunk stability for carryover with transfers.
bilateral integration techniques and Neuromuscular Development Techniques (NDT) to facilitate crossing mid-line and facilitate patterned movements, joint compression to LUE x 15 seconds with clinician supporting elbow and wrist, D1/D2 patterns 3 sets of 10.
Therapist directed pt in reaching outside base of support during unsupported sitting activity to increase trunk stability for carryover with transfers.
Skilled interventions focused on crossing midline to facilitate independence in functional skill performance, dynamic balance activities during sitting and strengthening activities to increase functional task performance.
Skilled interventions focused on crossing midline to facilitate independence in functional skill performance, balance activities during sitting and strengthening activities to increase functional task performance
Skilled interventions focused on crossing midline to facilitate independence in functional skill performance, and strengthening activities by reaching for object away from to increase functional reach and static sitting balance to promote increase participation with task.
Neuro-Re-ed
bilateral integration techniques and Neuromuscular Development Techniques (NDT) to facilitate crossing mid-line and facilitate patterned movements, joint compression to LUE x 15 seconds with clinician supporting elbow and wrist, D1/D2 patterns 3 sets of 10.
Ther Ex: therapeutic resistance exercises, closed chain kinetic exercises, bicep curls, triceps curls and therapeutic exercises for UE to facilitate independence in self-care tasks. Self-Care Mngmt: safety training during transitional movements, energy conservation during ADLs, bathing skill training, toileting skill training, dressing techniques, initiation cues to facilitate skill performance and techniques to increase safety for ADLs in sitting. Therapeutic Activities: gross motor coordination, crossing midline to facilitate independence in functional skill performance, bilateral integration, dynamic balance activities during sitting, dynamic balance activities while sitting and standing and placement of objects out of reach to increase dynamic skill performance, toilet transfer training, shower chair transfer training, safety awareness training and energy conservation technique training needed for ADL independence.
Facilitate by optimizing scapulothoracic, shoulder, and upper back ROM and posture
Incorporate into ADL training
Clinician provided R UE resistive exercises via shoulder flexion, elbow flexion, extension and grip flexion targeting deltoid, bicep, triceps, and intrinsic/extrinsic muscles of the hand to assist with UB dressing, self-feeding, and oral hygiene.
Pt min to no progress noted this reporting period due to decrease treatment session secondary to treating therapist out (self-quarantine) due to Covid-19 pandemic.
Pt progress through AAROM stretches to B shoulders glenohumeral joint in sagittal, frontal, and horizontal plane, elbows in sagittal plane and wrist in sagittal and frontal planes with prolong stretch at end range during e-stim to R anterior deltoid and bicep setting at LVPC Medium muscle disuse atrophy x 15 minutes 15.8 mA with skin integrity intact pre and post session.
E-Stim applied to B shoulders and biceps for purpose(s) of to facilitate muscle contraction, strength, decrease risk of falls, coordination and muscle power and intensity level/settings at Neuro-Re-ed Triphasic PENS 38 mA x 15 minutes with skin integrity intact pre and post session.
E-Stim Pain
E-Stim applied to left shoulder and right shoulder for purpose(s) of decreasing pain and intensity level/settings at IFC PREMOD Chronic Pain at 41 mA x 15 minutes with skin integrity intact pre and post e-stim.
E-Stim applied to anterior forearm to facilitate muscle contraction, strength, decrease risk of falls, coordination and muscle power and intensity level/settings at LVPC Asymmetrical Hand Control Biphasic Function Re-ed 38 mA x 15 minutes with skin integrity intact pre and post session.
E-Stim applied to B anterior deltoids and biceps for purpose(s) of to facilitate muscle contraction, strength, decrease risk of falls, coordination and muscle power and intensity level/settings at LVPC Medium Muscle Symmetrical Biphasic Muscle Disuse Atrophy PENS 34 MA x 15 minutes with skin integrity intact pre and post session.
E-Stim applied to R anterior/posterior deltoids, bicep and triceps for to facilitate muscle contraction, strength, decrease risk of falls, coordination and muscle power and intensity level/settings at Neuro-Re-ed Triphasic PENS 38 mA x 15 minutes with skin integrity intact pre and post session.
E-Stim applied to L thenar/hypothenar eminence, anterior/posterior forearm to facilitate muscle contraction, strength, decrease risk of falls, coordination and muscle power and intensity level/settings at Neuro-Re-ed Triphasic PENS 38 mA x 15 minutes with skin integrity intact pre and post session.
SPLINT
RUE Roll Hand splint; pt. currently tolerating splint x3 hours; Goal to tolerate splint x5hrs daily. Restorative to preform skin checks before and after.
Skilled intervention focused on application of B hand carrot splints in order to decrease risk of contracture and assist with hand hygiene and skin integrity. Pt tolerated hand splint x 2 hours with no signs of redness, pain or swelling.
Pt educated on safety precautions during transitional movements in order to facilitate.
Pt little/no progress secondary to few treatment sessions.
Pt little/no progress exhibited. Place on iso due to covid-19 pandemic.
Diathermy
Diathermy applied to Anterior forearm, wrist and hand for 15 minutes in order to increase range of motion with intensity level/settings at 2 Delta T with skin integrity intact pre and post session.
Diathermy applied to R lumbar for 15 minutes in order to reduce chronic pain, facilitate functional mobility and minimize negative effects of immobility with intensity level/settings at 2 Delta T with skin integrity intact pre and post session. Pt reported decrease lumbar pain post diathermy of 2/10 (improved from 3/10 at start of session).
Concurrent
Patient participated in concurrent therapy with 1 other patient to successfully progress towards individual treatment plan/goals by addressing patient's balance deficits, ROM, gross motor coordination deficits and safety awareness deficits; skilled interventions included static/dynamic, sitting balance, therapeutic and aerobic exercises, and education on safety precautions.
Patient participated in concurrent therapy with 1 other patient to successfully progress towards individual treatment goals by addressing patient's balance deficits, decreased ROM, gross motor coordination deficits and safety awareness deficits; skilled interventions included static and dynamic sitting balance activities to increase trunk strength, therapeutic and aerobic exercises, and education on safety precautions to decrease fall risk and promote independence with toilet commode transfers. Pt tolerance session with min rest breaks during session.
Group
Patient participated in group therapy with 2 other patients to successfully progress towards individual treatment plan/goals by addressing patient's balance deficits, decreased ROM, gross motor coordination deficits and safety awareness deficits; skilled interventions included static/dynamic sitting balance, aerobic exercises and education on safety precautions to decrease risk of falls and promote independence with ADLs. Pt able to tolerate session well this date.
Patient participated in group therapy with 2 other patients to successfully progress towards individual treatment plan/goals by addressing patient's balance deficits, BUE strength, gross motor and fine motor coordination deficits and safety awareness deficits; skilled interventions included static/dynamic sitting balance by reaching for objects from pt's reach to facilitate core strength, aerobic exercises and education on safety precautions to decrease risk of falls, increase FIST score to 38/56 and facilitate independence with LB dressing.
Patient participated in group therapy with 2 other patients to successfully progress towards individual treatment plan/goals by addressing patient's balance deficits, BUE strength, gross motor and fine motor coordination deficits and safety awareness deficits; skilled interventions included static/dynamic sitting balance by reaching for objects from pt's reach to facilitate core strength, aerobic exercises and education on safety precautions to decrease risk of falls, increase Modified Barthel Index to 50/100 and facilitate independence with UB dressing, LB dressing, oral hygiene and toilet commode transfers.
Patient participated in group therapy designed to successfully progress patient by addressing patient's balance deficits, gross motor coordination deficits, fine motor coordination deficits, decreased safety awareness and safety awareness deficits ; skilled interventions of focus included core strengthening, BUE aerobic and strength training targeting deltoids, biceps and triceps to assist with ADL independence with 1 patient participated in the group.
Patient participated in group therapy with 1 other patient designed to successfully progress patient by addressing patient's balance deficits, gross motor coordination deficits, fine motor coordination deficits, decreased safety awareness and safety awareness deficits; skilled interventions of focus included core strengthening, BUE aerobic and strength training targeting deltoids, biceps and triceps to facilitate independence with UB dressing, oral hygiene and toilet commode transfers.
W/C Mngmt: training in locking/unlocking brakes to facilitate safety and training in safe maneuvering through doorways.
Clinician provided B exercises targeting deltoids, biceps, and triceps in order to facilitate muscle strength, coordination, ROM and activity tolerance in order to increase independence in order to ADLs.
Skilled interventions focused on patient's ability to perform Dressing tasks included dressing techniques and safety training during transitional movements. Skilled interventions to facilitate safety and independence with IADLs included energy conservation during IADLs. Pt's O2 at 95% during session with Min verbal/visual cues to return demonstration of energy conservation techniques.
Pt educated on toilet hygiene task and safety precautions in order to facilitate independence with daily activities. Pt at S/U for Ub bathing, LB dressing and donn/doff socks and shoes with Reacher. Pt requires Supervised A for perineal hygiene during toileting task. Pt at independence with self-feeding, S/U with oral hygiene and required Supervised A for problem solving.
Pt could not be accommodated with rehab tx schedule due covid protocol and conflict with nursing staff schedule.
Skilled interventions focused on training in log rolling technique to increase independence in bed mobility tasks. Pt required Total A to roll from side to side to decrease risk of skin break down. Maximum improvement is yet to be attained. Pt demonstrated increase L and R PROM shoulder flexion of 5 degrees this reporting period. Pt demonstrated 0/100 on Modified Barthel Index and 0/56 on FIST score this reporting period. Pt <30 seconds on activity tolerance.
Diathermy applied to left shoulder for 15 minutes in order to increase range of motion with intensity level/settings at 2 Delta T with skin integrity intact pre and post session.
Pt demonstrated increase L and R PROM shoulder flexion of 10 degrees this reporting period.
Maximum improvement is yet to be attained. Pt demonstrated 0/100 on Modified Barthel Index, 1/56 on FIST score this reporting period. Pt showed 30 to 60 seconds increase activity tolerance.
Pt will tolerate R hand carrot splint for 2 hours without signs of redness, pain, or swelling in order to decrease risk of contractures and assist with hand hygiene.
Increase technical wording, put actual joint and muscles. glenohumeral joint
% of cues and type of cues
Pain levels
% of deficits before and improvement after activity
Add which goal UB goals
Before/After
Assess their movements
External Oblique
Rectus abdominis
Pt required Max verbal/tactile cues to initiate task this date. Pt's temperature at 97 degrees.
Pt Max A for supine to sit at EOB to increase static sitting balance and activity tolerance in order to facilitate increase time of out the bed and facilitate independence with ADLs. Pt able to sit upright with Max A from clinician to activate core strength. Pt able to tolerate sitting at EOB x 10 minutes with poor static sitting.
Clinician provided passive stretches to B glenohumeral joint sagittal, frontal, and horizontal plane, elbows in sagittal plane and wrist in sagittal and frontal planes with prolong stretch at end range to decrease risk of contractures and increase ROM to facilitate independence with UB dressing and oral hygiene. Pt required Max cues to initiate task with adverse reaction pulling away BUE during session.
Diathermy applied to left shoulder for 15 minutes in order to increase range of motion and enhance functional skills during daily living tasks with intensity level/settings at 2 Delta T with skin integrity intact and post session.
Pt showing progress as results of skilled interventions. Pt increase UB dressing, LB dressing, toilet hygiene at Supervised A. Pt able to bath self with Supervised A while following safety precautions using grab bars for task completion. Pt demonstrated increase Modified Barthel Index of 67/100 this reporting period.
RNP
5 x a week x 12 weeks 15 minutes or as tolerated.
Pt. benefits from S/U of meals, and orientation; benefits from verbal cueing to initiate self feeding.
Fall Risk, confusion, behavior risk. Monitor vitals.
Benefits from monitored aerobic and resistive exercises.
Pt fall risk, diabetic and cardiac precautions, and monitor respiratory.
Pt benefits from monitored and resistive BUE exercises.
balance deficits, safety awareness deficits, decreased safety awareness, fine motor control deficits, gross motor coordination deficits, decreased ROM, decreased static balance and strength impairments.
Continued OT services are necessary to increase independence with ADLs, increase safety awareness, facilitate independence with ADLs, facilitate dynamic standing balance, increase functional activity tolerance, assess safety and independence with ADLs and assess safety and independence with self-care and functional tasks of choice in order to be able to return to prior level of living, perform UB ADLs with increased independence and safety and perform LB ADLs with increased independence and safety. Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: falls, depression, social isolation, pressure sores, decreased skin integrity, decreased ability to return to prior level of assistance, decreased ability to return to prior living environment, malnutrition and weight loss.
Continued OT services are necessary to increase independence with ADLs, increase safety awareness, facilitate independence with ADLs, facilitate dynamic standing balance, increase functional activity tolerance, assess safety and independence with ADLs and assess safety and independence with self-care and functional tasks of choice in order to be able to return to prior level of living, perform UB ADLs with increased independence and safety. Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: falls, depression, social isolation, pressure sores, decreased skin integrity, decreased ability to return to prior level of assistance, decreased ability to return to prior living environment, malnutrition and weight loss.
Clinician provided BUE resistive and aerobic exercises via shoulder flexion, elbow flexion/extension, and grip strength 3 sets of 10 targeting deltoids, biceps, triceps and intrinsic/extrinsic muscles of the hand to facilitate muscle strength, power, coordination and cardio to increase participation with daily activities such as UB dressing, LB dressing and self-feeding.
Skilled interventions focused on safety precautions during transitional movements in order to facilitate independence with ADLs. Pt was able to perform UB dressing using one hand techniques with Max A in 3/3 trials.
Clinician provided BUE resistive and aerobic exercises via shoulder flexion, elbow flexion/extension, and grip strength 3 sets of 10 targeting deltoids, biceps, triceps and intrinsic/extrinsic muscles of the hand to facilitate muscle strength, power, coordination and cardio to increase participation with daily activities such as UB dressing and toilet commode transfers. Pt demonstrated increase R hand grip strength of 14.3 kg and 10.1 kg of L hand grip strength.
Skilled interventions focused on crossing midline to facilitate independence in functional skill performance, dynamic balance activities during sitting and strengthening activities to increase functional task performance. Pt demonstrated increase activity tolerance of 10 minutes during task.
Pt seen to measure progress toward POC this date. Pt able to perform toilet commode transfers at Max A using grab bar for support. Pt able to perform UB dressing with Mod A showing progress. Pt demonstrated increase Modified Barthel Index scored at 25/100.
W/C Mngmt: training in locking/unlocking brakes to facilitate safety.
Ther Ex: therapeutic resistance exercises, closed chain kinetic exercises, bicep curls, tricep curls and therapeutic exercises for UE to facilitate independence in self care tasks. Self Care Mngmt: safety training during transitional movements, energy conservation during ADLs, oral hygiene, dressing techniques, initiation cues to facilitate skill performance and techniques to increase safety for ADLs in sitting. Therapeutic Activities: gross motor coordination, crossing midline to facilitate independence in functional skill performance, bilateral integration, dynamic balance activities during supine, placement of objects out of reach to increase dynamic skill performance, safety awareness training, energy conservation technique training.
Skilled services provided by therapist this reporting period, as well as with assistant.
decreased problem solving and decreased awareness. balance deficits, safety awareness deficits, decreased static balance and decreased ROM.
Continued OT services are necessary to increase independence with ADLs, increase safety awareness to perform UB ADLs with increased independence and safety. Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for falls.
Continued OT services are necessary to improve rehab potential, increase functional activity tolerance, increase independence with ADLs, increase safety awareness, facilitate sitting tolerance and postural control, facilitate independence with ADLs, assess safety and independence with ADLs and assess safety and independence with self-care and functional tasks of choice in order to be able to return to prior level of living, perform UB ADLs with increased independence and safety and safely return home . Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: falls, contracture(s), depression, limited out-of-bed activity, immobility and further decline in function.
Clinician provided BUE resistive and aerobic exercises via shoulder flexion, elbow flexion/extension, and grip strength via restorator with min resistance, 1 lb dowel and thera-band targeting deltoids, biceps, triceps and intrinsic/extrinsic muscles of the hand to facilitate muscle strength, power, coordination and cardio to increase participation with daily activities such as UB dressing and toilet commode transfers.
Skilled interventions focused on crossing midline to facilitate independence in functional skill performance, dynamic balance activities during sitting and strengthening activities to increase functional task performance.
Skilled interventions focused on safety during transitional movements and UB dressing. Pt educated on UB dressing techniques by threading BUE through sleeve of sweater with Mod A in 3/3 trials.
W/C Mngmt: training in safely removing wheelchair arm / leg rests, training in locking/unlocking brakes to facilitate safety and instruction in maneuvering in small spaces.
Pt fall risk, hx of CVA, dysphagia, severe dementia, aphasia, wound to sacrum wound to R and L hip, a fib, and pacemaker.
Pt benefits from ROM of BUE and sitting up in w/c.
Pt was instructed in safety during transitional movements in order to decrease fall risk and promote independence with UB dressing and toilet commode transfers. Pt able to dress UB with Mod A showing progress toward POC. Pt required Mod A to complete toilet commode transfers using grab bars showing progress toward goals.
Skilled interventions focused on family training for safety precautions during bed to wheelchair transfers and toilet commode transfers. Clinician educated family daugthers Letty, Lorena, and son-in-law Joe on proper body mechanics, hand/foot placement, and safety sequence of bed <> wheelchair and wheelchair<>toilet commode transfers. Pt/family understood instructions and return demonstration of functional transfers with good recall. Clinician educated pt/caregiver on assistive devices and equipment to safely transition home.
Pt instructed in in safety precautions during transitional movements to decrease fall risk and promote independence with functional transfers. Pt educated on UB dressing techniques to promote independence with ADLs with S/U to thread BUE through sleeves and pull garment overhead. Pt required additional time to perform sit to stand from EOB to wheelchair.
Clinician instructed patient in BUE resistive and aerobic exercises including shoulder flexion and elbow flexion/extension. Therapeutic exercises targeted deltoids, biceps and triceps to increase muscles strength, coordination of BUE needed for UB dressing and toilet commode transfers.
Clinician guided pt to floor secondary to pt's knees buckling during transfers. Charged nurse Alina was notified. Pt's temperature at 97.1 degrees.
decreased attention skils, moderate cognitive impairment and reduced problem solving skills.
eliminate distractions, quiet location for treatment and use low stimulation environment for treatment.
Skilled interventions focused on crossing midline to facilitate independence in functional skill performance, balance activities during sitting and strengthening activities to increase functional task performance. Pt able to tolerate session well and able to maintain sitting balance during dynamic sitting activities.
BUE resistive exercises including shoulder flexion, elbow flexion and extension to facilitate muscle contracture, tolerance and coordination. Therapeutic exercises targeting deltoids, biceps, triceps in order to increase independence with ADLs. Pt required min verbal cues to initiate task. Pt required Min rest breaks.
HTN, blindness, diabetic precautions, allergic to morphine, NWB to RLE, displace R femoral neck fx, S/P TMA, fall risk, O2 AT 2L/min via NC PRN.
Pt benefits from sitting upright in chair for meals to decrease aspiration and increase social participation. Pt benefits from aerobic and monitored BUE exercises.
Pt benefits from divided plate for meals.
Fall risk, foley cath placement, and HTN. Pt benefits from sitting upright during meals to decrease risk of aspiration.
Bilateral Upper Extremity therapeutic exercise, including shoulder extension, shoulder flexion, hand MCP flexion, elbow flexion, elbow extension and shoulder external rotation seated unsupported to enhance core muscle strength in order to enable increased participation in self care tasks and assist with transitional movements.
Clinician provided BUE resistive and aerobic exercises via shoulder flexion, elbow flexion/extension, and grip strength 3 sets of 10 targeting deltoids, biceps, triceps and intrinsic/extrinsic muscles of the hand to facilitate muscle strength, power, coordination and cardio to increase participation with daily activities such as UB dressing, LB dressing, and bathing.
Pt required Supervised A to dress UB due to increase AROM of R shoulder of 65 degrees. Pt was able to tolerance session of 20 minutes before taking rest break. Pt demonstrated 18/56 on FIST score this reporting period. Pt required Mod A to stand x 1 min in order to assist with toilet commode transfers.
Patient participated in group therapy with 1 other patient to successfully progress towards individual treatment plan/goals by addressing patient's balance deficits, decreased ROM, gross motor coordination deficits and safety awareness deficits; skilled interventions included static/dynamic sitting balance, aerobic exercises and education on safety precautions to decrease risk of falls and promote independence with ADLs. Pt able to tolerate session well this date.
NWB to LLE, stroke with left sided weakness, fall risk. Pt benefits from monitored BUE aerobic and resistive exercises.
Pt training in safety during transfers to carryover with toilet commode transfers. Pt required supervised A to transfer using standard walker. Pt required min verbal cues for proper hand/foot placement and leaning forward while pushing off bed to ease sit to stand and complete task.
Patient participated in concurrent therapy with 1 other patient to successfully progress towards individual treatment goals by addressing patient's balance deficits, decreased ROM, gross motor coordination deficits and safety awareness deficits; skilled interventions included static and dynamic sitting balance activities to increase trunk strength, therapeutic and aerobic exercises, and education on safety precautions to decrease fall risk and promote independence with toilet commode transfers.
L resting hand splint and L dynapro flex elbow orthosis
4 hours on 4 hours off, or as tolerated
4 hours on 4 hours off, or as tolerated w/o s/s of redness, swelling, or skin breakdown
fall risk, HTN, peg, skin integrity, confusion, decreased vision, keep HOB elevated >45 degrees
CVA w/L sided hemiplegia, gastronomy status, atrial fibrillation, heart failure, edema, HLD, HTN, CAD, glaucoma, vascular dementia, dysphagia, NSTEMI
Manual Tx: joint mobilization techniques and stretching of shortened connective tissue to L elbow, shoulder and wrist to decrease risk of contracture and promote ROM.
RUE resistive exercises including shoulder flexion, elbow flexion, extension and grip flexion. Therapeutic exercises targeting deltoids, biceps, triceps and intrinsic/extrinsic muscles of the hand to promote independence with ADLs. Pt tolerated session well this date.
Pt educated on application of L shoulder brace to decrease risk of subluxation with good return demonstration. Pt educated in safety during sit to stand during transfers to decrease fall risk and promote independence with LB dressing. Pt required Max A to thread BLE through slacks and pull to waist to complete task.
max/TD+ for bed mobility tasks
unable to coordinated with nurse for due to unavailable this date.
Pt demonstrated S/U for UB dressing and Mod A for LB dresisng this reporting period. Pt met goal of 15 minute activity tolerance this reporting period. Pt also demonstrated decrease pain of 3/10 during session this reporting period. Pt demonstrated 24/56 on FIST.
Passive stretches to L wrist in sagittal and frontal planes with prolong stretch at end range with no joint compression due to pain to L thumb during session. Charged nurse Roxanne was notified.
BUE resistive exercises via shoulder flexion, elbow flexion/extension and grip flexion. Therapeutic exercises targeting deltoids, biceps, triceps and intrinsic/extrinsic muscles of the hands to facilitate independence with oral hygiene, UB dressing and functional transfers. Pt required Mod verbal cues throughout session to initiate task.
Patient participated in concurrent therapy with 1 other patient to successfully progress towards individual treatment plan/goals by addressing patient's balance deficits, ROM, gross motor coordination deficits and safety awareness deficits; skilled interventions included static/dynamic, sitting balance, therapeutic and aerobic exercises, and education on safety precautions.
Fall risk, fall precautions, low bed padded floor mats, monitor vitals, stage 2 coccyx.
Pt benefits from monitor BUE aerobic and resistive exercises.
Skilled interventions focused on patient's ability to perform Dressing tasks included dressing techniques and initiation cues to facilitate skill performance. Pt required Mod A to thread BUE through sleeves and pull garment overhead to complete task.
Patient participated in group therapy designed to successfully progress patient by addressing patient's balance deficits, gross motor coordination deficits, fine motor coordination deficits, decreased safety awareness and safety awareness deficits ; skilled interventions of focus included core strengthening, BUE aerobic and strength training targeting deltoids, biceps and triceps to assist with ADL independence with 1 patient participated in the group.
Skilled interventions focused on safety during transitional movements in order to decrease fall risk and promote independence with self-care task. Pt educated on UB dressing techniques with Partial A to thread BUE through sleeves and pull garment overhead to complete task. Pt