RESIDENT: Order received, Chart reviewed and assessment performed. See IE for details.
NEW: Obtained subjective history including past medical history and precautions, assessed for levels of transfer and gait. Patient responded well to initial evaluation and treatment. Patient does have a low tolerance to activities that will have to be improved, but was able to tolerate the full session. Discussed with patient (AND WHO) the impairments present that are impacting functional mobility and ADL. Educated patient (AND WHO) on the purpose of Skill Physical Therapy and the responsibility of the patient to participate with in task to address deficits. Established and discussed LTGs and POC. Patient agreed to participate in skilled PT and did not have any remaining questions on the LTG or POC.