Assessment
Plan
Superbill
Arrival info
Treatment
Assessment
<patient> was seen for skilled Physical Therapy intervention focused on increasing trunk and core musculature strength, improve balance and coordination during transitional activities, decrease risks and incidences of falls and promote normal developmental pattern. Patient completed obstacle course such as walking on the 4 inch balance beam, walking on the foam line, walking on foam steps, and stepping over wooden obstacles with occasional HHA x 1 required due to occasional LOB. Overall, treatment was good.
<patient> was seen for skilled Physical Therapy intervention focused on increasing trunk and core musculature strength, improve balance and coordination during transitional activities, decrease risks and incidences of falls and promote normal developmental pattern. Patient was able to complete balance and coordination activities (various obstacles) such as walking on the 4 inch balance beam, walking on the foam line, walking on foam steps, and stepping over wooden obstacles with occasional HHA x 1 required due to occasional LOB. Pamela required close SBA when kicking a moving ball due to occasional LOB during single-leg phase. No fall occurred during treatment. Overall, treatment was good.
The patient received skilled Physical Therapy intervention aimed at improving trunk and core musculature strength, enhancing balance and coordination during transitional activities, reducing the risk of falls, and promoting a normal developmental pattern. During the treatment session, a variety of activities were performed, including walking on a 4-inch balance beam, navigating a foam line, stepping on foam steps, stepping over wooden obstacles, using a treadmill, playing hopscotch, and engaging in single-leg stance (SLS) throwing and catching exercises. These activities challenged the patient's balance and coordination skills, with occasional assistance from a home health aide (HHA) needed for stability during certain tasks due to occasional loss of balance (LOB). Importantly, no falls occurred during the treatment session. Overall, the patient demonstrated positive progress, showing improvements in trunk and core strength, balance, coordination, and the ability to perform dynamic tasks involving SLS throwing and catching.
Arrival information Subjective
<patient> was able to focus better in therapy today.
COVID19 PRECAUTIONS: Hand washing, face mask and body temperature check.
Plan for next visit
<patient> tolerated treatment well. Continue with current plan of care as per supervising PT. Alteration may occur when needed. Joseph Obnial, PTA. Supervising Physical Therapist: Annie Marie Esguerra, P.T., DPT
<patient> tolerated treatment well. Continue with current plan of care as per supervising PT. Alteration may occur when needed. Joseph Obnial, PTA. Supervising Physical Therapist: Annie Marie Esguerra, P.T., DPT
Plan of care includes therapeutic exercises to improve mobility of her trunk and bilateral lower extremity musculature; postural training to improve postural awareness and orientation; manual therapy; heat modality (PRN); balance and coordination exercises to improve gait skills; and patient education to train her on home exercise program. Assessment findings and recommendations including frequency and duration of treatment were discussed with patient’s mother who verbalized understanding and agreement. Alteration may occur when needed. Joseph Obnial, PTA. Supervising Physical Therapist: Annie Marie Esguerra, P.T., DPT