Weebly
Student’s Name: Andrea Strickland Date: 5-24-14
SLCC Physical Therapist Assistant Program
Patient’s Initial Evaluation Homework Assignment
Initials of Patient (1 point): JC
Date seen by Physical Therapist (1 point): 5-16-14
Age (1 point): 59
Diagnosis (Including DOI, DOO or DOS) (3 points): Generalized muscle weakness and difficulty in walking following CABG surgery, Coronary atherosclerosis of VE
Medications (2 points): Atorvastatin, Lantus, acetaminophen, Metoprolol Tartrate, Losartan Potassium, Effient, Amlodipine Besylate, Lamotrigine, Omeprazole, Levothroid, Hydrocodone, Humalog.
Medical Issues (past and present) (2 points): pt is at risk for cardiac insufficiency, compromised general health, falls, and further decline in function, CABG. Hx, CAD, type II DM, HTN, hyperlipidemia, chronic kidney disease, and seizure disorder.
|Pertinent information obtained from|Total: 40 points |
|chart review entered by Physical | |
|Therapist during “Patient’s Initial|1. Range of Motion Measurements: RLE=WFL, LLE=WFL (this was all that was stated in initial eval, there are no goniometric numbers). |
|Evaluation.” | |
|(Medicare #: 97001) |2. Manual Muscle Test (MMT): RLE strength = 4/5, LLE strength = 4/5. |
| | |
| |3. Additional Data Collection: Respiratory status = WFL, Skin Integrity= redness in some areas, no edema, intact sensation, intact visual spatial perceptual skills. |
| | |
| |4. Bed Mobility (Move up and down in bed, supineEOB, etc): SBA ( all that was specified in chart) |
| | |
| |5. Transfers (Sitstand, bedw/c, w/c mat, etc): CGA which includes stairs, W/C N/A |
| | |
| |6. Sitting: Static sitting = Good, Dynamic sitting = Good (maintains balance w/o support against mod resistance) |
| | |
| |7. Standing: Static standing = Fair ( maintains standing balance 1-2 min w/o UE support w/o LOB). Dynamic standing = Fair- ( Min (A) or UE support to stand w/o LOB &|
| |reach ipsilaterally; unable to weight shift) |
| | |
| |8. Ambulation/Stairs: CGA with stairs, Gait = CGA; distance level surfaces 150 ft w/ FWW. Uneven surfaces CGA 5 ft. w/ FWW. Pt exhibits forward |
| | |
| |9. Special Tests: None specified in chart |
| |Patient’s Goals: “I would like to get back to walking, community mobility, and household chores”. |
| | |
| |Short Term Goals (5 points): |
| |Pt will increase dynamic standing balance to G-/F+ spontaneously righting self when needed and w/o LOB and w good safety awareness in order to reduce the risk for |
| |falls and improve ability to safely ambulate w/in environment (Target 5/29/14) |
| |Pt will safely ambulate on level surfaces 350’ using FWW w/ supervised (A) w normalized gait pattern and with functional dynamic balance 90% of the time with reduced |
| |risk for falls and w/o SOB to increase independence w/ all functional ambulation (target 5/29/14). |
| |Pt will safely perform functional transfers w/ supervised (A) w/ good safety awareness and w/o signs/symptoms of physical exertion in order to return to prior level |
| |of functional abilities (5-29-14). |
| | |
| | |
| |Long Term Goals (5 points): |
| |Pt will safely ascend/descend 12 stairs w/ supervised (A) using handrails bilaterally for use of energy conservation techniques w/o SOB (Target 6-12-14). |
| |Pt will increase ability to safely ambulate Unlimited Distances within the community using least restrictive assistive device w/ Supervised (A) w/ reduced risk for |
| |falls w/o SOB (Target 6-12-14). |
| | |
| |Physical Therapist’s Plan of Care/Planned Interventions (10 points): |
| |Neuromuscular reeducation (97112) to improve standing and dynamic balance |
| |Gait training therapy (97116) to improve ambulation w/ assistive devices |
| |Therapeutic Activities (97530) to get pt back to previous level of function |
| |Therapeutic exercises (97110) to strengthen and improve all functional abilities |
| | |
|Student Analysis of Physical |Contraindications (i.e. movement precautions, aspiration history and head must be 35 degrees or higher in supine position, etc) (3 points): Sternal precautions, so pt|
|Therapist’s Information |cannot push down on walker to stand or lift more than 5#, etc. HTN, need to take vitals and allow pt to rest when needed, sensation loss in feet. |
| | |
| |Safety Considerations for the Patient (i.e. cardiac history, aspiration with clear fluids, pacemaker, atrial fibrillation, dementia, COPD, on supplemental O2, etc.) |
| |(5 points): HTN, diabetes, cardiac hx, and seizure disorder. |
| | |
| |Additional Information Needed and Rationale (MMT, ROM measurements, etc.) (4 points): MMT and ROM were taken to evaluate if pt had normal measurements in LE’s to |
| |accomplish goals. 0/10 pain scale at rest and w/ movement |
|Functional Problem List (10 points): |
|1. Pt requires FWW during ambulation w/CGA |
|2.Pt has bil LE strength at 4/5 influenced by general muscle weakness |
|3. Pt has a “fair” static and “fair-“ dynamic standing balance, unable to weight shift |
|4. Pt has deficits in safety awareness, gait, and activity tolerance |
|5. Pt is at risk for falls |
|Questions for Physical Therapist Related to Initial Evaluation (5 points): |
|1. Why was there no numbers for the goniometric measurements? |
|2. Why was there no special tests administered to evaluate the LE muscles? |
|3. Why does the MMT just say RLE or LLE strength, instead of specific muscle groups? |
|4. Why was a FWW selected because the pt is on sternal precautions? |
|Equipment Considerations (3 points): Gait belt for ambulation and transfers, FWW, pulse oximeter |
SLCC Physical Therapist Assistant Program
Weekly Patient Progress Note Assignment
Daily Treatment Notes for Week (25 points/daily note, total of daily notes/number of daily notes= average out of 25 points):____________
|Date: 5-21-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Sternal precautions, no lifting over 5#, HTN, fall risk |
|Patient’s medical status: Unchanged |
|S: Pt stated that he was feeling great with no pain and anxious about his discharge because he had to move within the next couple weeks. |
|O: Pt, PTA, and SPTA attended a POC meeting at the beginning of tx to discuss therapy, to see if pts goals were being met and to see about a discharge date which was not stated at meeting. After|
|meeting pt did ambulate with FWW around facility with CGA. A Balance Berg Test was administered with an overall score of 37/56 to get a better understanding of balance deficits and what needs to |
|be focused on during therapy. Pt did need UE support during balloon toss activities when he would lose his balance, especially when his feet were together (decrease BOS) w/CGA. 0/10 pain scale |
|through tx. |
|A: Pt did well during balance activities but did require UE support in case of LOB. Most of pts tx was in a POC meeting where therapy and other issues were addressed with facility |
|representatives. Balance Berg Test score of 37/56. |
|P: Pt needs to continue to work on balance and safe ambulation around facility with FWW so he can return to previous level of function. |
|Problem(s) encountered by SPTA and outcome(s): Only issue is that I do not have a previous tx to compare this tx with. |
|Changes that need to be communicated to PT/nurse: Pt did communicate with PT about being able to ambulate around facility w/ FWW independently. |
|Date: 5-22-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Sternal precautions, no lifting over 5#, HTN, fall risk |
|Patient’s medical status: Unchanged |
|S: Pt stated that he was feeling good and ready for therapy before tx. He also stated that his standing tolerance is not that good. |
|O: Biodex for 20 min w/ resistance of 10. After 5 min of tx pt complained of pain in the R knee and the resistance was dropped to 0. MHP to R knee with 5 layers of towels, 15 min, and mild, |
|blanchable erythema noted after tx. Pain scale 7/10 before MHP and 4/10 after tx. Pt did require approximately 6 rest breaks during Biodex tx, RPE 11/20, and SOB 3/10. Dynamic Gait Index test |
|issued after ther ex with a total score of 17/24 (predictive of falls in the elderly). Pt required a FWW during all tests and used bil hand rails during stair test. Pt did bean bag toss in |
|modified tandum stance requiring UE support within reach in case of LOB and CGA. Pt did sway but did not rely on UE support. |
|A: Pt did progress balance exercises to a modified tandum stance w/o relying on UE support. Pt does need to work on cardiopulmonary endurance to facilitate function and return to previous level |
|of function. Safety was emphasized during ambulation including sternal precautions. Dynamic Gait Index score of 17/24 which is an increased risk for falls. |
|P: pt will continue w POC to facilitate independence in community activities and potentially for discharge. |
|Problem(s) encountered by SPTA and outcome(s): none |
|Changes that need to be communicated to PT/nurse: none |
|Date: 5-23-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Sternal precautions, no lifting over 5#, HTN, fall risk |
|Patient’s medical status: Unchanged |
|S: Pt stated he was feeling well and that there was no pain in his right knee today. He was wondering about discharge which he was told to talk to the PT. |
|O: Biodex for 20 min requiring 4 rest breaks, 0 resistance. Gait training with FWW, CGA emphasizing safety awareness inside and outside the facility. CGA during stair training to prepare pt for |
|discharge and to use stairs at home. Pt did need verbal cues to keep all of the right foot on the step for safety reasons. Vitals were taken after each set of ascending/descending stairs. Pt |
|required UE support to complete balance training tasks while standing on foam. Balance activities were to facilitate ankle and hip strategies to help right self and fall prevention. Pt |
|participated in LE strength activities, mini squats 2*10 sets. Pt was unable to complete total number without rests d/t fatigue in quads. 0/10 pain scale. |
|A: Pt tolerated ther ex with less rest breaks then previous tx. O2 sat rates did stay above 90% before and after each exercise. Pt reported no pain in right knee during tx. Pt does require CGA |
|during all ambulation and stair training and does need verbal cues to remember safety precautions and keep proper posture. |
|P: Continue with POC, strengthening, balance, and gait activities to return to previous level of function and increase activity tolerance. |
|Problem(s) encountered by SPTA and outcome(s): None |
|Changes that need to be communicated to PT/nurse: None |
| |
| |
Summary of Weekly Patient Progress Note(s)
Rationale for Daily Plan of Care (75 points):
*Note: Summarize daily treatment notes within each square.
|Modalities Used: hot pack on right |Why Selected? The hot pack was selected |Outcome(s): Pt reported a 7/10 pain scale before |Progression (If no change, why?) modalities could be adjusted |
|knee to decrease pain. |because the pt could ride the biodex while |tx and it dropped to 4/10 after hot pack. |according to pts pain. But since the pt only had the hot pack one|
| |receiving pain tx. | |day out of the week I did not see a reason for trying another pain|
| | | |modality. |
|Therapeutic Exercises (Medicare # |Why Selected (muscle exercise directed to and|Provided Outcome(s): |Explain Progression (If no change, why?) |
|97110): |why)? | | |
|1. mini squats |1. mini squats was used to strengthen the |1. pt was unable to complete the total number of |1. pt did not progress because he could not complete the reps w/o |
|2. biodex |quads because we noticed LE weakness as pt |reps given and required a rest to complete task. |taking a rest. |
| |was ascending/descending stairs. |2. biodex to increase activity tolerance and |2. pt is slightly progressing endurance as he started taking less |
| |2. biodex was used at the beginning of each |strengthen LE’s. |rests in the last tx compared to the first tx. |
| |tx as a warm up | | |
|Neuromuscular Activities (balance |Why Selected? |Provided Outcome(s): |Progression and Why? |
|activities for sitting, standing, |Dynamic gait was selected to see if pt was at|Test results 17/24. Pt does have the chance for |No progression (test) |
|etc.) (Medicare # 97112): |risk for falls |falls |No progression (test) |
|Dynamic Gait Index |Berg Balance was also selected for fall risk |Test results 37/56. Pt does have the chance for |Pt did progress from the floor to foam. He did need UE support |
|Berg Balance Test |Standing activities to test dynamic balance |falls |and always required CGA for safety reasons. |
|Standing balance activities |in different surfaces and pertabations |Standing balance did challenge pt and help him | |
| | |learn some ankle strategies to right himself and | |
| | |help LOB | |
| | | | |
|Therapeutic Activities (Bed mobility|Why Selected? |Provided Outcome(s): |Progression and Why? |
|and transfers that includes assistive|To improve transfer activities w/ FWW and |To improve transfers from CGA to SBA then complete|As patients LE strength and activity tolerance improve, he will be|
|device if needed, assistance |teach safety measures during the activities |independence for discharge |able to progress to the least restrictive device safely and only |
|required, etc.) (Medicare # 97530):| | |use one hand rail on the stairs. |
|Transfers from exercise equipment and| | | |
|mat table to FWW w/ CGA | | | |
|Gait (Include assistive device(s) if |Why Selected? |Provided Outcome(s): |Progression and Why? |
|used, level of assistance needed, |FWW was selected because it has the most UE |The better the pt ambulates with the FWW, he will |Pt can already ambulate for unlimited distances. Quad cane |
|distance, gait abnormalities, etc.) |support and to prevent falls. Pt does need to|be able to progress to the least restrictive |training should be the next step. |
|(Medicare # 97116): |remember his sternal precautions. |device which is a long term goal. | |
|Gait w/ FWW and CGA during therapy | | | |
|(pt requested to be able to ambulate | | | |
|w/ FWW w/o assistance around the | | | |
|facility, the PT gave approval). Pt | | | |
|can ambulate unlimited distances | | | |
|Other: None |Why Selected? |Provided Outcome(s): |Progression and Why? |
|Goals Met (3 points): |Date Accomplished: |
|1. N/A |1. . N/A |
|2. | |
|3. |2. |
| |3. |
|New Goals Initiated (3 points): |Date Initiated: |
|1. N/A |1. . N/A |
| | |
|2. |2. |
|3. |3. |
|Interventions that were beyond scope of work or knowledge as a SPTA (2 points): None so far. |
SLCC Physical Therapist Assistant Program
Weekly Patient Progress Note Assignment
WEEK 2
Daily Treatment Notes for Week (25 points/daily note, total of daily notes/number of daily notes= average out of 25 points):____________
|Date: 5-26-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Sternal precautions, no lifting over 5#, HTN, fall risk |
|Patient’s medical status: Unchanged |
|S: Pt stated he was feeling well and reported no pain. Pt did state that he could have worked harder during the ex. Pt also stated that he had visual deficits during outside ambulation d/t sun|
|glare. |
|O: Biodex, 20 min, no resistance, 3 rest breaks, SOB scale 3/10 and PRE scale 11/20 to improve LE strength and endurance. Pt required CGA during ambulation w/ FWW and on stairs. Pt required a few|
|VC’s to keep right foot entirely on each step on the descend. Pt demonstrated a marked time pattern while ascending the stairs. Pt required multiple VC’s to keep in a straight line and to avoid|
|obstacles while ambulating outside the facility. Pt ambulated 150’, 175’, 200’, 350’, requiring rest breaks between distances for approximately one minute d/t fatigue. |
|A: Pt did progress during on the Biodex bike requiring less rest breaks compared to previous tx. Pt did not progress on the stairs because he marked time on the ascend when he previously used |
|one foot per step. |
|P: Continue w/ POC and pt education about safety while ambulating in the community and avoiding obstacles. |
|Problem(s) encountered by SPTA and outcome(s): None |
|Changes that need to be communicated to PT/nurse: None |
|Date: 5 27-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Sternal precautions, no lifting over 5#, HTN, fall risk |
|Patient’s medical status: Unchanged |
|S: Pt stated that he was feeling well and had no pain, but that he wasn’t feeling well earlier on in the morning. He is very anxious for |
|discharge. |
|O: Pt required CGA-mod A during inside and outside gait training w/ FWW for safety reasons and to help with pts LOB over uneven ground. Pt |
|was able to go 250’, 250’, 200’, and 350’, pt required one minute rests between each distance d/t fatigue. Biodex, 20m min, resistance 3, PRE|
|scale 10/20, SOB scale 3/10 to improve LE strength and increase activity tolerance. Dynamic balance activities to facilitate proper standing |
|posture and emphasize balance on uneven terrain, also to use ankle/hip strategies while on uneven ground during dynamic activity. Pt required|
|CGA- mod A during balance tasks which he demonstrated frequent LOB, especially when bending over to pick up objects off the grass. |
|A: Pt did progress resistance on Biodex, but then needed more rest breaks than previous tx, and had muscle cramps in his calves. Pt did |
|progress to an unstable surface to do balance activities which required mod A to keep him from falling. |
|P: Continue w/ POC and working on balance activities on uneven ground. Pt should wear sun glasses while ambulating outside to help w/ visual |
|deficits. Pt should continue ther ex to improve cardiopulmonary endurance and LE strength. |
|Problem(s) encountered by SPTA and outcome(s): None |
|Changes that need to be communicated to PT/nurse: None |
| |
|Date: 5-28-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Sternal precautions, no lifting over 5#, HTN, fall risk |
|Patient’s medical status: Unchanged |
|S: Pt stated that he was feeling better than he did yesterday. |
|O: Biodex, 20 min, resistance 3, 4 rest breaks, RPE scale 12/20, SOB scale 1/10 to increase endurance and Le strength. Pt progressed FWW to a|
|SPC requiring mod A. Pt tends to lean heavily on cane and has a choppy gait pattern during gait training inside and outside the facility. Pt |
|needed frequent rests approximately every 50’ d/t fatigue. Pt had frequent LOB w/ SPC outside and needed to switch back to FWW for safety and |
|to help improve activity tolerance. Pt demonstrated a marked time pattern during stair training in both directions, and seemed more unstable |
|wanting to use both hand rails instead of one at times requiring CGA. |
|A: Pt did progress to SPC but was very unstable requiring mod A assist instead of CGA. Pt did use ankle and hip strategies to stay upright |
|during LOB. Pt did complete ther ex but still requires several rests. Pt does display good safety awareness while performing ADL’s in room. |
|Pt will benefit from skilled therapy to improve LE strength, balance, and coordination. |
|P: Continue with POC and working on a more normalized gait pattern w/ SPC. |
|Problem(s) encountered by SPTA and outcome(s): None |
|Changes that need to be communicated to PT/nurse: None |
| |
| |
|Date: 5-29-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Sternal precautions, no lifting over 5#, HTN, fall risk |
|Patient’s medical status: Unchanged |
|S: Pt stated that he was feeling good and that today was going to be his last day at rehab. He decided that he was ready to leave even though|
|it was against medical advice. |
|O: Biodex, 20 min, resistance 4, 5 rests, RPE scale 12/20, SOB scale 2/10 to increase endurance and LE strength. Berg Balance Test score of |
|41/56 which was a progression from previous score of 37/56. Pt still shows substantial deficits in balance. Pt could not stand in tandum |
|stance, on one foot, and had LOB on the step test. |
|A: Pt did progress his Berg Balance Test score to 41/56, previous score 37/56. Pt is still at risk for a potential fall. Pt can complete |
|ther ex with more r3esistance but still requires many rests d/t fatigue in the LE’s. Pt has inadequate balance and endurance to complete |
|ADL’s safely and independently. |
|P: Continue with Home Health to improve gait w/ assistive devices, stair training, balance, coordination, and strength. |
|Problem(s) encountered by SPTA and outcome(s): None |
|Changes that need to be communicated to PT/nurse: None |
| |
Summary of Weekly Patient Progress Note(s)
Rationale for Daily Plan of Care (75 points):
*Note: Summarize daily treatment notes within each square.
|Modalities Used: |Why Selected? |Outcome(s): |Progression (If no change, why?) |
|None – not needed | | | |
|Therapeutic Exercises (Medicare # |Why Selected (muscle exercise directed to and|Provided Outcome(s): |Explain Progression (If no change, why?) |
|97110): |why)? | | |
|1.Biodex |1. To warm up LE’s before tx |1.To increase endurance |1. No progression, pt did add resistance, but he still required |
| | | |several rests to complete ther ex. |
|Neuromuscular Activities (balance |Why Selected? |Provided Outcome(s): |Progression and Why? |
|activities for sitting, standing, |Selected to see if pt has progressed |Test results 41/56 compared to previous score of |Berg Test score did progress by 4 points, but the pt is still in |
|etc.) (Medicare # 97112): |To improve balance and posture |37/56. |the category for a risk of a fall. |
|Berg Balance Test | |Dynamic balance exercises to help pt learn how to |No progression w/ balance. Pt is still very unstable with all |
|Dynamic standing activities | |use ankle/hip strategies. |balance activities. The reason could be neuropathy in feet, or |
| | | |decreased strength in both LE’s. |
|Therapeutic Activities (Bed mobility|Why Selected? |Provided Outcome(s): |Progression and Why? |
|and transfers that includes assistive|To promote safety and independence |Pt did all transfers independently w/ SBA |Pt did show an improvement in transfers from CGA to SBA. |
|device if needed, assistance | | | |
|required, etc.) (Medicare # 97530):| | | |
|Transfers w/FWW | | | |
|Gait (Include assistive device(s) if |Why Selected? |Provided Outcome(s): |Progression and Why? |
|used, level of assistance needed, |Pt was able to ambulate w/ FWW requiring SBA |Good pt on his way to independence w/ FWW |Pt does very well w/ FWW and shows descent safety awareness inside|
|distance, gait abnormalities, etc.) |FWW selected because it is the most stable AD|Good choice to keep sternal precautions until pt |the facility. He does not need CGA anymore. |
|(Medicare # 97116): |SPC was selected by pts choice, but required |becomes more stable |No progression w/ FWW. He has always done well on even surfaces. |
|SBA |mod assistance |Pt was very unstable w/ the SPC as he required |No progression w/ SPC. He has to work on LE strength, balance, |
|FWW | |more assistance and his gait pattern was more |and coordination in order to progress to cane. |
|SPC w/mod A | |compromised | |
|Other: NONE |Why Selected? |Provided Outcome(s): |Progression and Why? |
|Goals Met (3 points): |Date Accomplished: |
|1. None, Pt decided to leave against medical advice |1. None |
|2. |2. |
|3. |3. |
|New Goals Initiated (3 points): |Date Initiated: |
|1. None |1. None |
|2. |2. |
|3. |3. |
|Interventions that were beyond scope of work or knowledge as a SPTA (2 points): None |
Student’s Name: Andrea Strickland WEEK 3 Date:
SLCC Physical Therapist Assistant Program - Patient’s Initial Evaluation Homework Assignment
Initials of Patient (1 point): DB
Date seen by Physical Therapist (1 point): 6-1-14
Age (1 point): 60
Diagnosis (Including DOI, DOO or DOS) (3 points): Aftercare following joint replacement in left hip due to a fall, generalized muscle weakness, difficulty in walking.
Medications (2 points): Enoxaparin sodium, Oxycodone HCL, Aspirin, Atorvastatin calcium, Fluticasone propionate, Lamotrigine, Oxybutynin, Tylenol, Tubersol, Tramadol, Baclofen, Neurontin, Multivitamins, Potassium.
Medical Issues (past and present) (2 points): Fx to left trochanter of femur, CVA in 1999 resulting in left sided paresis, seizure disorder, subdural hemotoma, neurogenic bladder.
|Pertinent information obtained from|Total: 40 points |
|chart review entered by Physical | |
|Therapist during “Patient’s Initial|1. Range of Motion Measurements: RLE ROM= WFL; LLE ROM=impaired (ORIF + paresis, tone) |
|Evaluation.” | |
|(Medicare #: 97001) |2. Manual Muscle Test (MMT): RLE strength = 3-/5; LLE strength = 1/5 |
| |Trunk = 3-/5 |
| | |
| |3. Additional Data Collection: HR at rest = 89 beats/min; tone and posture symmetrical posture throughout; LLE tone, spastic; gross motor coordination = impaired; |
| |sensation = impaired; vision = intact; cognition = safety awareness = impaired |
| | |
| |4. Bed Mobility (Move up and down in bed, supineEOB, etc): Total dependence w/ attempts to initiate |
| | |
| |5. Transfers (Sitstand, bedw/c, w/c mat, etc): Total dependence w/ attempts to initiate; sit stand = total dependence w/ attempts to initiate |
| | |
| |6. Sitting: Static = unable, total dependence Dynamic = unable, total dependence |
| | |
| |7. Standing: Static = unable, total dependence Dynamic = unable, total dependence |
| | |
| |8. Ambulation/Stairs: Level surfaces = Total dependence w/o attempts to initiate; Distance level surfaces = N/A; Assistive Device = DNT; Uneven Surfaces = DNT |
| | |
| |9. Special Tests: None specified in chart |
| |Patient’s Goals: “ I want to be able to walk to the bathroom”. |
| | |
| |Short Term Goals (5 points): |
| |Pt will increase trunk strength to 5/5 in order to increase core strength for functional activities and facilitate upright posture (target 6-28-14) |
| |Pt will increase RLE strength to 4+/5 to facilitate pts ability to perform transfers w/ SBA w/ use of AD while maintaining good balance and w/ implementation of |
| |compensatory strategies in order to facilitate increased independence w/ functional mobility throughout facility (target 6-28-14) |
| |Pt will increase static sitting balance to g-/F+ spontaneously righting self when needed in order to participate in EOB activities and facilitate safety coming to |
| |stance (target 6-28-14) |
| |Pt will increase static sitting balance to fair-spontanously righting self when needed and w/ability to right self to achieve balance w/ implementation of |
| |compensatory strategies in order to prepare for gait activities and decrease need for A during mobility/ ADL’s (target 6-28-14) |
| | |
| |Long Term Goals (5 points): |
| |Pt will safely perform functional transfers w/ modified independence w/ minimal pain and w/ improved ROM and coordination in order to safely return to private |
| |residence w/ reduced risk for falls. |
| |Pt will safely ambulate 30 feet using SPC on level surfaces w/ modified independence w/ ability to right self to achieve balance and w/ minimal pain in order to allow|
| |pt to get to bathroom w/ decreased assistance (target 6-28-14) |
| | |
| |Physical Therapist’s Plan of Care/Planned Interventions (10 points): |
| |Therapeutic exercises (97110) |
| |Neuromuscular reeducation (971120 |
| |Gait training therapy (97116) |
| |Therapeutic activities (97530) |
| |Frequency: 5 times per week |
| |Duration: 4 weeks |
| |Intensity: Daily |
| | |
| | |
|Student Analysis of Physical |Contraindications (i.e. movement precautions, aspiration history and head must be 35 degrees or higher in supine position, etc) (3 points): None Specified in chart |
|Therapist’s Information | |
| |Safety Considerations for Patient (i.e. cardiac history, aspiration with clear fluids, pacemaker, atrial fibrillation, dementia, COPD, on supplemental O2, etc.) (5 |
| |points): fall risk, seizure disorder, WB as tolerated, complicated medical hx |
| | |
| |Additional Information Needed and Rationale (MMT, ROM measurements, etc.) (4 points): pain at rest 4/10 constant in left hip; pain with movement 10/10 occasional in |
| |left hip |
|Functional Problem List (10 points): |
|1. Pt has limited core strength. |
|2. Pt has no strength in LLE due to CVA in 1999, and had hip surgery on this side. |
|3. Pt is at high risk for falls. |
|4. Pt is terrified of putting weight on her left leg and when she gets nervous her tone sets in then she can’t move for transfers. |
|5. Pt is totally dependent with all transfers, bed mobility, and ADL’s. |
|Questions for Physical Therapist Related to Initial Evaluation (5 points): |
|1. Why was there no special tests performed on pt? |
|2. Why was there no goniometric measurements taken? |
|Equipment Considerations (3 points): Parallel bars, Omnicycle, Biodex, ankle weights, sliding board, leg lifter |
SLCC Physical Therapist Assistant Program – Weekly Patient Progress Note Assignment
Daily Treatment Notes for Week (25 points/daily note, total of daily notes/number of daily notes= average out of 25 points):____________
| |
|Date: 6-2-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Fall risk, seizure disorder |
|Patient’s medical status: Unchanged |
|S: Pt stated that she had a lot of pain in her left hip at the surgery incision and asked us to move her very slow and steady. |
|O:Pt required mod x2 for all bed mobility activities, transfers, and to get to the toilet. Pt required a lot of time for each transfer d/t pain in the left hip. Pt is unable to move left leg |
|independently because of CVA. Pt participated in bed mobility exercises to strengthen the right foot; 3 min of ankle pumps, heel slides and leg lifts, needing rests between each exercise. MHP |
|during the ex to decrease pain in left quad, 9 towel layers, 15 min, mild, blanchable erythema noted after tx. Pt required CGA during seated balance exercises d/t weak core and pore posture. Pt |
|required mod x 2 to pull up to standing w/ UE support, pt was able to stand for 6.5 min until she needed a seated rest. |
|A: Pt requires a lot of time for transfers and bed mobility d/t left paresis and hip syrgery. Pt is very afraid of falling and needs constant reassurance. Pt also needs multiple cues to stay on |
|task as she wants to do things her way, but are inefficient and unsafe. |
|P: Continue w/ POC, and focus on putting weight on left leg to help w/ transfers. |
|Problem(s) encountered by SPTA and outcome(s): Only problem is the pt is very heavy and terrified of moving. I feel bad, and wish there was more I can do, but she has to move and trust us that |
|we wont drop her. The outcome was good, she was proud of herself that she stood for 6 min. |
|Changes that need to be communicated to PT/nurse: She definitely needs her pain medication before therapy. |
| |
| |
| |
|Date: 6-3-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Fall risk, seizures |
|Patient’s medical status: unchanged |
|S: Pt stated that she was ready for therapy and wanted to stand longer then previous day. Her sister was w/ her for support. |
|O: Omnicycle to increase activity tolerance and LE strength. 20 min, resistance 2, 88% activity level, rests only to help reposition left foot d/t clonus attacks. MHP to left quad to decrease |
|pain, 15 min, 9 towel layers, mild, blanchable erythema noted after tx. Pt participated in a FIST test w/ a score of 46/56. Pt required mod 2 assist during all transfers from w/c to mat table, |
|and max assist to pull up to standing w/ UE support. |
|Pt requires many verbal and manual cues to position left foot to stand or transfer and also to use right leg and arm more to help w/ motion. Pt was able to stand for 10 min before needing a |
|seated rest. |
|A: Pt did progress standing activities to 10 min from 6.5 in the previous tx. Pt still requires a lot of assistance to move or complete ADL’s. Pt did a FIST test w/ a score of 46/56, the |
|deficits from the test was lateral scooting and reaching d/t pain in left hip. Pt is still terrified to move, but it seemed she was more confident today. I think it is because she had the |
|support of her sister. |
|P: continue w/ POC |
|Problem(s) encountered by SPTA and outcome(s): None |
|Changes that need to be communicated to PT/nurse: None |
| |
|Date: 6 4-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Fall risk, seizures |
|Patient’s medical status: Unchanged |
|S: Pt stated that she was doing well with little pain and ready for therapy. |
|O: Biodex to increase activity tolerance and LE strength. 20 min, 0 resistance, SOB scale 0/10, pain scale 7/10, RPE scale 6/20. Pt required max x 2 assist to get on the bike which took about 20|
|min total to transfer. Pt began to get very afraid of falling and needed constant verbal and manual cues to position feet and use right leg and arm to help. MHP to left quad to decrease pain, 15|
|min, 9 towel layers, mild, blanchable erythema noted after tx. Pt required max x 2 to transfer off bike and into w/c, this transfer took about 30 min. Pt began to really feel unsteady and |
|anxious. When the pt started to get uptight her tone would kick in and make her motionless. Pt required constant reassurance, verbal, and manual facilitation to pivot feet and put some weight |
|on left leg to help right foot turn. Pt was struggling so we put a turn table under her feet to help her turn her feet and sit in w/c. |
|A: Pt still needs assistance for all activities and ADL’s d/t inadequate strength, coordination, and balance to complete tasks independently. Most of the tx time today was spent on transferring. |
|P: Continue w/ POC. |
|Problem(s) encountered by SPTA and outcome(s): Pts fear of falling to where her tone kicks in and makes her motionless. Pt really had a hard therapy session today and it could have gone so much |
|smoother. The outcome was good because she didn’t fall even though I thought she might a couple times. She literally got paralyzed w/ fear. |
|Changes that need to be communicated to PT/nurse: Maybe anti anxiety meds?? |
| |
|Date: 6-5-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Fall risk |
|Patient’s medical status: Unchanged |
|S: Pt stated that she was very tired and not feeling well. |
|O: Pt required mod x2 assist to come up to standing w/ UE support. Pt was able to weight shift onto the left foot which pt stated that it wasn’t painful. Pt progressed to lift right hand off |
|support while putting weight on left foot and would lift right toes up. Pt did this for about 10 min. Omnicycle, 20 min, resistance 3, RPE scale 6/20, pain scale 8/10, SOB scale 0/10, rests |
|only to position left foot d/t spasticity. MHP to left quad to decrease pain, 15 min, 9 towel layers, mild, blanchable erythema noted after tx. Pt began to complain about nausea during ther ex.|
|After ther ex pt wanted to go back to her room. Pt still had 30 min of tx time and was offered alternative activities to complete for therapy but insisted on leaving. |
|A: Pt did progress standing exercise by adding weight shifts to bear more weight on left foot, pt was able to lift right hand and toes to also. Pt began to feel nauseous after ther ex and |
|insisted on leaving. Pt has poor activity tolerance and strength to complete tasks and ADL’s independently and safely. Pt still requires assistance for all activities and would benefit from |
|continuing skilled therapy to improve these deficits. |
|P: Continue w/ POC |
|Problem(s) encountered by SPTA and outcome(s): None |
|Changes that need to be communicated to PT/nurse: None |
| |
|Date: 6-6-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Fall risk, seizures |
|Patient’s medical status: Unchanged |
|S: Pt stated that she was feeling better than yesterday and said she was a little upset at Sam and I for not putting her back into bed when she left therapy yesterday. |
|O: Pt required mod assist to get sat up on edge of bed to begin transfering to w/c. Pt required CGA while sitting on edge of bed d/t weak core muscles and lack of use of left arm. Pt was able to|
|scoot onto w/c but needed mod assist to get situated in seat. Pt participated in seated transferring activities from mat table to w/c, scooting the right side of body towards destination. Pt |
|does require assist to get in position d/t pain in the left leg. Omnicycle, 20 min, resistance 3, rests to get left foot positioned d/t spasticity, SOB scale 0/10, RPE 5/20, pain scale 7/10. |
|MHP to left quad, 15 min, 9 towel layers, mild, blanchable erythema noted after tx. |
|A: Pt did well on scooting activities but did need assistance to get fully positioned at end of movement. Pt is beginning to move a little faster, but still requires lots of time to complete any|
|transferring activity. Pt still gets very nervous w/ fast movements and will insist you to slow way down so her left leg can catch up to her. Pt still requires assistance with all activities and|
|would benefit from continuing skilled therapy to improve activity tolerance, strength, and transfers. |
|P: Continue W/ POC. |
|Problem(s) encountered by SPTA and outcome(s): None |
|Changes that need to be communicated to PT/nurse: None |
Summary of Weekly Patient Progress Note(s)
Rationale for Daily Plan of Care (75 points):
*Note: Summarize daily treatment notes within each square.
|Modalities Used: |Why Selected? |Outcome(s): |Progression (If no change, why?) |
|Hot Pack |To decrease pain in the left quad |Pt stated that it helped after every tx |No progression, pts surgery site is on the left hip, so it still |
| | | |is painful most of the time. |
|Therapeutic Exercises (Medicare # |Why Selected (muscle exercise directed to and|Provided Outcome(s): |Explain Progression (If no change, why?) |
|97110): |why)? | | |
|1. Omnicycle |1. To warm up muscles and keep left foot |1. Pt was able to do full minutes but had to stop |1. No progression, pt is still on same resistance and time. Pt has|
|2.Biodex |strapped in place |frequently to keep left foot positioned d/t |to stop often to reposition foot |
|3. Bed exercises |2. To warm up muscles and use arms at same |spasticity |2. No progression, we only tried this machine once because its too|
| |time |2. Pt was able to complete exercise, but it took |complicated to use at this time d/t the time it takes to get her |
| |3. easy exercises pt can do while in bed |about 50 min to transfer to and from bike , so its|on/off it. |
| | |not a very time efficient activity |3. No progression, we only practiced these exercises once while |
| | |3. Good outcomes, pt stated that they are easy for|treating this pt. |
| | |her to do while in bed | |
|Neuromuscular Activities (balance |Why Selected? |Provided Outcome(s): |Progression and Why? |
|activities for sitting, standing, |None |None |Havn’t done these activities yet because it’s such a chore to get |
|etc.) (Medicare # 97112): | | |pt just to transfer. We are working on transfers and standing |
|None | | |balance first which my CI said is considered therapeutic |
| | | |activities instead of neuro. |
| | | | |
|Therapeutic Activities (Bed mobility|Why Selected? |Provided Outcome(s): |Progression and Why? |
|and transfers that includes assistive|To get pt accustomed to putting weight on |Standing balance is going good |There is progression w/ standing. Pt is able to start putting |
|device if needed, assistance |left foot to help us w/ transfers. |Sitting balance needs a lot of work |more weight on left leg |
|required, etc.) (Medicare # 97530):|Sitting activities to help her strengthen |Transfers and bed mobility need a lot of work also|Sitting has not progressed because pt always has help coming to |
|Standing activities, sitting |core muscles | |sit and never attempts to do it alone |
|activities, transfers, and bed |Transfers and bed mobility to help her become| |Transfers and bed mobility are progressing in the time it takes |
|mobility activities |independent | |because that’s what we practice the most, but it still requires at|
| | | |least half the tx time. |
|Gait (Include assistive device(s) if |Why Selected? |Provided Outcome(s): |Progression and Why? |
|used, level of assistance needed, |None |None |Have not even attempted gait training, Pt cant even stand w/o |
|distance, gait abnormalities, etc.) | | |support and cannot use walker yet d/t pain in hip and atrophy of |
|(Medicare # 97116): | | |left leg. This is the pts main goal and we are working on |
|None | | |strengthening those legs and standing first. |
|Other: None |Why Selected? None |Provided Outcome(s): None |Progression and Why? None |
|Goals Met (3 points): |Date Accomplished: |
|1. none |1. none |
|2. |2. |
|3. |3. |
|New Goals Initiated (3 points): |Date Initiated: |
|1. none |1. none |
|2. |2. |
|3. |3. |
|Interventions that were beyond scope of work or knowledge as a SPTA (2 points): None |
WEEK 4
SLCC Physical Therapist Assistant Program – Weekly Patient Progress Note Assignment
Daily Treatment Notes for Week (25 points/daily note, total of daily notes/number of daily notes= average out of 25 points):____________
| |
|Date: 6 -9 -14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Fall risk, seizures |
|Patient’s medical status: Unchanged |
|S: Pt stated that she had a good weekend and that she was ready for therapy. Pain scale 8/10. |
|O: Omnicycle to improve activity tolerance and LE strength. 20 min, 89% activity level, SOB 0/10, RPE 13/20. MHP on left hip and knee to decrease pain, 15 min, 9 towel layers, mild, blanchable |
|erythema noted after tx. Dynamic standing activities using mat table and berry rehab board to facilitate weight shifting to prepare for gait. Pt requires many verbal, manual, and tactile cues to |
|stay on task and shift weight onto left foot. Pt used a mirror to see that she leans too much to the right to keep weight off left side. Pt was able to tap right toes, but had a hard time |
|lifting right heel. Pt was able to scoot herself into w/c w/ SBA. Pt required CGA while sitting on edge of bed 40 % of the time during bed mobility activities. |
|A: Pt progressed the time it takes to transfer and was able to scoot herself into w/c w/ SBA. Pt still has a hard time shifting weight onto left foot to help make transfers easier and faster. |
|Pt still complains of severe pain in left hip but overall is trying her best. Pt has poor activity tolerance, strength, and standing balance to participate in ADL’s safely and independently. Pt |
|will benefit from continuing skilled therapy to improve these areas. |
|P: Continue to work on independent transfers and standing tolerance. |
|Problem(s) encountered by SPTA and outcome(s): None |
|Changes that need to be communicated to PT/nurse: None |
| |
|Date: 6-10-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: fall risk, seizures |
|Patient’s medical status: Unchanged |
|S: Pt stated that she was feeling well, pain scale was 7/10. |
|O: Biodex to improve activity tolerance. 10 min, no resistance, no rests. MHP to left hip and groin area to decrease pain. 7 towel layers, 10 min, mild, blanchable erythema noted after tx. Pt |
|did CKC exercises w/ pillow case under left foot but cannot on the right d/t inability to put weight on left foot. Pt participated in standing exercises w/ UE support. Pt was able to stand and |
|cross mid line to grab objects in attempt to weight shift on left foot. Pt still demonstrated difficulty in weight shifting even when objects were moved further away. Pt requires multiple cues |
|to stay on task and upright during standing activities. Pt required SBA for 50 % of transfers and min assist for the other 50%. |
|A: Pt is improving on transfers only requiring SBA while she scoots herself into w/c or mat table. Pt is able to pull herself up to stand w/ many attempts. Pt is still having pain in left hip |
|that is affecting her ability to weight shift on left leg. Pt needs to work i=on this task in order to ambulate. Pt progressed to Biodex bike instead of Omnicycle d/t her ability to transfer more|
|efficiently. |
|P: Continue to weight shift and increase standing tolerance. |
|Problem(s) encountered by SPTA and outcome(s): None |
|Changes that need to be communicated to PT/nurse: None |
| |
|Date: 6-11-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Fall risk, seizures |
|Patient’s medical status: None |
|S: Pt stated that she was fine and ready for therapy. Pain scale 7/10. |
|O: Pt required SBA for 80% of transfers and min assist 20 %. Pt is able to scoot herself into w/c or mat table w/ SBA. Pt is able to pull herself to standing using UE support and requiring |
|assistance 20% of the time. Biodex to improve activity tolerance and LE strength. 20 min, 0 resistance, no rests, SOB scale 0/10, RPE scale 7/20. MHP to left knee and hip to decrease pain, 9 |
|towel layers, 15 min, mild, blanchable erythema noted after tx. Pt was put on unweighted system to improve weight shifting tolerance to prepare for gait training. Pt was able to shift to left |
|side leaning into the left bar on mat table. Pt practiced moving right foot back and forth using targets on the floor. Pt completed 6 steps then required a seated rest. Pt did complain of left |
|hip pain throughout activity. |
|A: Pt progressed to Biodex bike because she is able to transfer more efficiently. Pt was able to put some body weight on left foot because she was hooked up to the unweighted system. Pt still |
|needs to work on putting all body weight on left foot and standing posture. Pt has poor activity tolerance and balance. Pt will benefit from continuing skilled therapy to improve these areas. |
|P: Continue to progress standing activities, transfers, and LE strength to prepare for ambulation. |
|Problem(s) encountered by SPTA and outcome(s): None |
|Changes that need to be communicated to PT/nurse: None |
| |
|Date: 6-12-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Fall risk, seizures |
|Patient’s medical status: Unchanged |
|S: Pt stated that she was tired and nervous for what we had in store for her today. She stated that she does not like the unweighted system. |
|O: Pt is able to transfer needing SBA while scooting into w/c or mat table. Pt requires mod assist to come to stand. Pt stresses herself out during transfers at times which makes her very |
|anxious to complete transfer. Pt needs lots of encouragement and support when this happens. Pt works best when you give short precise cues as of what to do next and where to place feet during |
|stand pivot transfers. Pt did not want to use unwieghted system so she participated in dynamic standing activities using UE support on both sides. Pt was unable to weight shift onto left foot |
|d/t pain in left hip, until we provided targets for her to put feet to. Pt was able to slowly scoot right foot to targets. Pt required several verbal, tactile, and manual cues to move feet |
|during stranding activity and to stay on task. Biodex to improve activity tolerance and LE strength. 20 min, 0 resistance, no rests, SOB scale 0/10, RPE scale 6/20. MHP on left knee and hip area|
|to decrease pain, 15 min, 9 towel layers, mild, blanchable erythema noted after tx. |
|A: Pt still cannot put weight onto left leg to improve standing tolerance. Pt is still doing good on transfers and pulling herself to stand. Pt is still complaining of pain in left hip and is |
|always asking why she is hurting so bad. Pt has poor standing and activity tolerance and would benefit from continuing skilled therapy to improve these deficits. |
|P: Continue to use unweighted system to facilitate weight shifting to prepare for gait training. |
|Problem(s) encountered by SPTA and outcome(s): None |
|Changes that need to be communicated to PT/nurse: None |
| |
|Date: 6-13-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Fall risk, seizures |
|Patient’s medical status: Unchanged |
|S: Pt stated that she was tired but willing to do whatever we asked today. Pain scale 5/10. |
|O: Pt required SBA for all seated transfers and mod assist for stand pivot transfers on/off toilet and on/off mat table. When doing stand pivot transfers, pt needs multiple verbal and tactile |
|cues as of where to go and what to do next. Pt was put on unweighted system to facilitate standing tolerance and weight shifts. Pt was able to roll a ball under right foot while standing on |
|left. Pt still leaned into mat table but completed task. Pt did this activity using a platform walker to support the right arm. Pt was able to take very small and slow steps w/ both feet. |
|Biodex to improve activity tolerance and LE strength. 20 min, 0 resistance, no rests, SOB 0/10, RPE 6/20. MHP to left knee and hip to decrease pain and stiffness, 15 min, 9 towel layers, mild, |
|blanchable erythema noted after tx. |
|A: Pt progressed standing activity using unweighted system while rolling a ball under her right foot to put weight on left. Pt is still doing good on transfers and pulling herself to stand. Pt |
|complains of pain in hip but is trying to prepare herself for ambulation. Pt has poor activity tolerance and strength to participate in ADL’s safely and independently. |
|P: Continue using unweighted system to facilitate weight shifting to begin gait training. |
|Problem(s) encountered by SPTA and outcome(s): None |
|Changes that need to be communicated to PT/nurse: None |
Summary of Weekly Patient Progress Note(s)
Rationale for Daily Plan of Care (75 points):
*Note: Summarize daily treatment notes within each square.
|Modalities Used: |Why Selected? |Outcome(s): |Progression (If no change, why?) |
|Hot packs |To warm up tissues and decrease pain |Pt stated that she always feels better after hot |No progression w/ hot pack because its just to warm up and take |
| | |pack |pain away. |
|Therapeutic Exercises (Medicare # |Why Selected (muscle exercise directed to and|Provided Outcome(s): |Explain Progression (If no change, why?) |
|97110): |why)? | | |
|1.Omnicycle |1.to warm up |1. Pt completed exercises well |1. No progression, pt has a hard time keeping foot in the pedal of|
|2. Biodex |2.to warm up |2. Pt progressed to this bike and did well |this machine |
|3.CKC LE exercises |3.to strengthen LE’s for gait training |3. Pt was able to do left foot but not right one |2. Pt progressed to this machine because of her ability to |
| | |d/t pain in left hip/knee |transfer on/off it w/ confidence. |
| | | |3. Pt did not progress because she will not put weight on left |
| | | |foot d/t pain. |
|Neuromuscular Activities (balance |Why Selected? |Provided Outcome(s): |Progression and Why? |
|activities for sitting, standing, | |Pt didn’t like it but did what we asked |Pt does progress standing tolerance w/ unweighted system because |
|etc.) (Medicare # 97112): |To give pt comfort that she cant fall and to |Pt was able to shift some weight off right foot |it helps take some body weight off her feet. |
|Unweighted System |take some weight off her |for seconds at a time, and move foot towards |Pt progresses when she has targets to step too w/ feet but |
|Dynamic standing activities |To facilitate standing tolerance and prepare |targets on the floor. |requires lots of cues. |
| |for gait training. | | |
|Therapeutic Activities (Bed mobility|Why Selected? |Provided Outcome(s): |Progression and Why? |
|and transfers that includes assistive| | | |
|device if needed, assistance | | | |
|required, etc.) (Medicare # 97530):| | | |
|Pt is scooting herself in/out of w/c | | | |
|w/o using any devices. Pt also does | | | |
|not use devices with stand pivot | | | |
|transfers. She only uses w/c. | | | |
|Gait (Include assistive device(s) if |Why Selected? |Provided Outcome(s): |Progression and Why? |
|used, level of assistance needed, | | | |
|distance, gait abnormalities, etc.) | | | |
|(Medicare # 97116): | | | |
|Not yet, hopefully next week. I want | | | |
|to see her walk before I leave ( | | | |
|Other: None |Why Selected? |Provided Outcome(s): |Progression and Why? |
|Goals Met (3 points): |Date Accomplished: |
|1. None |1. None |
|2. |2. |
|3. |3. |
|New Goals Initiated (3 points): |Date Initiated: |
|1. None |1. None |
|2. |2. |
|3. |3. |
|Interventions that were beyond scope of work or knowledge as a SPTA (2 points): None |
| |
Week 5
SLCC Physical Therapist Assistant Program – Weekly Patient Progress Note Assignment
Daily Treatment Notes for Week (25 points/daily note, total of daily notes/number of daily notes= average out of 25 points):____________
| |
|Date: 6-16-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Fall risk, siezures |
|Patient’s medical status: Unchanged |
|S: Pt stated that she was doing good. |
|O: Pt required CGA for all gait training activities and transfers. Biodex, 10 min to warm up at level 1, then adj to 15 after 5 min to improve LE strength and activity tolerance. Weight shifting|
|exercises to increase weight tolerance on left foot. Pt was afraid to step w/ right foot and that left knee would buckle. Pt was able to step w right foot if manual pressure is applied to left |
|knee. |
|A: Pt presented improvements in weight shifting and able to move right leg forward during gait training. Pt will benefit from continuing skilled therapy to improve activity tolerance, strength, |
|and gait. |
|P: Continue w/ plan of care. |
|Problem(s) encountered by SPTA and outcome(s): None |
|Changes that need to be communicated to PT/nurse: Talk to PT about knee brace for gait |
| |
| |
| |
|Date: 6-17-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Fall risk, seizures |
|Patient’s medical status: unchanged |
|S: Pt stated that she was tired. |
|O: Biodex to improve activity tolerance and LE strength. 20 min, 0 resistance, SOB 4/10, RPE 4/20, Pain scale 4/10MHP to left knee during ther ex to decrease pain, 15 min, 9 towel layers, mild, |
|blanchable erythema noted after tx. Pt practiced gait training using platform walker and unweighted system. Pt went 4’ and was able to go backwards at a faster speed. Pt required SBA to CBA for |
|all transfers and coming to stand. |
|A: Pt isprogressing the time it takes to transfer and weight shifting but is still anxious about shifting 100 % weight on left leg. Pt still presents poor standing balance and activity tolerance.|
|Pt will benefit from continuing skilled therapy to improve these deficits. |
|P: Continue gait training w/ unweighted system. |
|Problem(s) encountered by SPTA and outcome(s): None |
|Changes that need to be communicated to PT/nurse: None |
| |
|Date: 6-18-14 Pt was seen by therapist on this day. |
|Change of orders by doctor: |
|Contraindications: |
|Precautions: |
|Patient’s medical status: |
|S: |
|O: |
|A: |
|P: |
|Problem(s) encountered by SPTA and outcome(s): |
|Changes that need to be communicated to PT/nurse: |
| |
|Date: 6-19-14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Fall risk, seizures |
|Patient’s medical status: Unchanged |
|S: Pt stated that she was tired. |
|O: Biodex to improve LE strength and endurance. 20 min, 0 resistance, RPE 12/20, SOB 6/10, pain 4/10 pain in left hip and left knee. MHP to left knee for 15 min during ther ex to decrease pain. |
|Pt reported that pack got too hot so another layer of towels was added. Mild, blanchable erythema to treated area after hot pack. Pt required assist of unweighted system and platform walker. Pt |
|was able to go 6’ which took 8 min w/ max VCs, pt took seated rest then attempting to go a longer distance, pt had trouble moving R leg d/t inability to weight shift on left leg. Pt completed 5 |
|more feet but it took much longer needing more Vs and manual assistance. |
|A: Pt progressed the distance that it took to ambulate then previous tx’s. Pt is still anxious of weight shifting. Pt will benefit from continuing skilled therapy to improve these deficits. |
|P: Continue w/ POC. |
|Problem(s) encountered by SPTA and outcome(s): None |
|Changes that need to be communicated to PT/nurse: None |
| |
|Date: 6-20 -14 |
|Change of orders by doctor: None |
|Contraindications: None |
|Precautions: Fall risk, seizures |
|Patient’s medical status: Unchanged |
|S: Pt stated that she was well and that she was going to walk for me my last day here. |
|O: Gait training to normalize gait pattern, training in increased BOS, adjustment of COM over BOS, training in correct hand/ foot placement during gait , weight shift during mobility, |
|facilitation of symmetrical stance. Pt required SBA during gait activities w/ platform walker and unweighted system. Pt was able to go 6’ then needed a seated rest. Pt attempted more gait |
|training but had trouble advancing LE’s and required manual and verbal cues but was still unable to complete task. Biodex to improve endurance, 20 min, 0 resistance, SOB 0/10, pain 0/10, RPE |
|4/20. Pt had IFC during tx to decrease pain. IFC, 4 electrodes, left knee, channel one 28mA, channel 2 41 mA, 15 min. Pt required SBA to CGA for all transfers and gait training. |
|A: Pt is still unable to fully weight shift to take normal strides. Pt is progressing with unweighted system but frequently gets very anxious and wants to stop. Pt has poor activity tolerance |
|and strength to complete ADL’s independently and safely. Pt will benefit from continuing skilled therapy to improve these areas. |
|P: Continue w/ POC |
|Problem(s) encountered by SPTA and outcome(s): None |
|Changes that need to be communicated to PT/nurse: None |
Summary of Weekly Patient Progress Note(s)
Rationale for Daily Plan of Care (75 points):
*Note: Summarize daily treatment notes within each square.
|Modalities Used: |Why Selected? |Outcome(s): |Progression (If no change, why?) |
|Hot packs |To decerase pain in left knee/hip. |Pt stated that they temporarily ease the pain. |No progression. |
|IFC | | | |
| | | | |
|Therapeutic Exercises (Medicare # |Why Selected (muscle exercise directed to and|Provided Outcome(s): |Explain Progression (If no change, why?) |
|97110): |why)? | | |
|1.Biodex |1. to warm up |1. pt stated that it does help warm up |1. No progession, pt needs to tolerate a faster pace and increase|
|2. |2. |2. |the resistance on the bike |
|3. |3. |3. |2. |
| | | |3. |
|Neuromuscular Activities (balance |Why Selected? |Provided Outcome(s): |Progression and Why? |
|activities for sitting, standing, | | | |
|etc.) (Medicare # 97112): | | | |
|None | | | |
|Therapeutic Activities (Bed mobility|Why Selected? |Provided Outcome(s): |Progression and Why? |
|and transfers that includes assistive|To support LUE and elp to support weight for |Pt has a hard time because she is used to letting |The platform walker is a progression because it puts er LUE in the|
|device if needed, assistance |weight shifting tolerance. |er LUE just hang down, she says that it balances |right position to help distribute body weight so pt can ambulate. |
|required, etc.) (Medicare # 97530):|w/c for transportation |her. | |
|Platform walker | |Good |Only progression using the w/c is pts ability to slide in/out of |
|wheelchair | | |it at a way faster speed,a nd w/SBA. |
|Gait (Include assistive device(s) if |Why Selected? |Provided Outcome(s): |Progression and Why? |
|used, level of assistance needed, |To help take weight off pt so she can |Pt was able to ambulate w/ the unweighted system. |The unweighted system is a progression because it helps take some |
|distance, gait abnormalities, etc.) |ambulate |Pt still has a hard time shifting weight. |weight off so pt is somewhat willing to take small steps. |
|(Medicare # 97116): | | | |
|Unweighted system | | | |
|SBA to CGA | | | |
|Up to 6’ | | | |
|Very small step lengths and inability| | | |
|to weight shift | | | |
|Other: None |Why Selected? |Provided Outcome(s): |Progression and Why? |
|Goals Met (3 points): |Date Accomplished: |
|1. None |1. None |
|2. |2. |
|3. |3. |
|New Goals Initiated (3 points): |Date Initiated: |
|1. None |1. None |
|2. |2. |
|3. |3. |
|Interventions that were beyond scope of work or knowledge as a SPTA (2 points): None |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.