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Skilled Documentation

In two weeks, the patient will need to meet specific functional goals in order to be discharged, including walking 50 feet at 1 meter/second, maintaining single limb stance for 3 seconds, scoring 50/56 on the Berg balance scale, and having quadriceps strength of 4+/5. The daily plan includes exercises for the right knee, transferring training, education on lifting techniques, ultrasound treatment, and exercises for the right shoulder to increase flexion. The patient also needs education on mobility, transfers, exercises, and activity modifications.

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19 views

Skilled Documentation

In two weeks, the patient will need to meet specific functional goals in order to be discharged, including walking 50 feet at 1 meter/second, maintaining single limb stance for 3 seconds, scoring 50/56 on the Berg balance scale, and having quadriceps strength of 4+/5. The daily plan includes exercises for the right knee, transferring training, education on lifting techniques, ultrasound treatment, and exercises for the right shoulder to increase flexion. The patient also needs education on mobility, transfers, exercises, and activity modifications.

Uploaded by

Eva
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Skilled Documentation Using Functional Assessments and Measures In two weeks (time frame), patient will demonstrate (patient

t specific): 1. Gait speed of 1 meter/second and distance of 50 feet (objective and measurable) to cross residential street safely (functional) for discharge to the community. 2. Single limb stance of 3 seconds independently (objective and measurable) to allow weight shift for safe stair climbing (functional). 3. A Berg balance score of 50 out of 56 (objective and measurable) for adequate balance to perform in room dressing independently (functional). 4. Quadriceps strength of 4+/5 (objective and measurable) for independence in sit to stand transitional movement without the use of arms for rising (functional).

DAILY:

Right knee extension, three sets, 10 repetitions, 10# weight, full range Transfer training bed to chair with sliding board Description of equipment provided (sliding board, long handles sponge) for home use Description of education/training provided (Pt educated in proper lifting technique from floor to chest height and able to demonstrate technique with up to 25 pounds) Ultrasound at 1.5 W/cm2 for 5' to the L medial knee joint

"Patient required verbal and manual cues to complete shoulder flexion and abduction exercises without substitution. Therapeutic exercise and right shoulder mobilization resulted in increased flexion from 90 to 110 allowing the patient/client to reach overhead and complete activities of daily living. Patient still unable to perform overhead activities needed in performance of job duties."

1. Education on bed mobility and transfers with proper spine positioning. 2. Reinforce basic post-op home exercise program including a. Diaphragmatic breathing b. Relaxation exercises c. Upper extremity extension isometric exercises 3. Increase tolerance to walking ( mile daily) or bike (15-30 min cardiovascular activity) 4. Reinforce sitting, standing and ADL modifications with neutral spine and proper body mechanics.

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