Click-to-copy documentation blurbs documentation for OTs and COTAs in skilled nursing. Free, no login.
Patient will tolerate AE (appropriate splint to be assessed) x 1 hour with no redness or swelling to manage contracture to LUE.
Patient will decrease risk for falls as evidenced by an increase in score to 16 inches on Modified Functional Reach Test indicating no risk for falls.
Patient will increase functional ax tolerance to 1 hour in order to increase participation within environment and QOL.
Patient will decrease risk for falls as evidenced by an increase in score to 56/56 on the FIST Test.
Patient will safely perform functional activities of choice for 2 hours w/o falls in order to facilitate ability to live in environment w/least amount of supervision and assistance.
16. Patient arrived at skilled OT complaining of 4/10 R shoulder pain limiting UE dressing tasks. Upon assessment, patient unable to raise RUE against gravity. Patient instructed in gravity eliminated reaching task on table top to increase R shoulder flexion, extension, horizontal abduction/adduction to improve ability for dressing tasks. OT provided intermittent tactile cues to reduce compensatory strategies and isolate targeted muscle groups needed for functional task. As patient's pain subsides, progress to against gravity reaching tasks next session.
20. Patient presents to skilled OT s/p fall in patient's bedroom resulting in L sided hip pain and overall weakness. Without OT, patient is at risk for further decline as patient lives alone and was I with all tasks. Due to L sided hip pain, patient having noted difficulty getting off low surface heights of bed. Patient instructed in variety of sit to stands, stands to sits from multiple surface heights to increase overall function. Patient required min A initially and was provided cues for technique including hand, feet, and trunk placement. By the 4th trial, patient was able to complete with supervision. Patient was also provided with pictorial handout providing adaptive equipment (bed risers) recommendations as a resource to heighten the bed to allow for smoother and less difficult transitions from his low bed if this continues to be an issue for him. Will require follow up next session to ensure independence.
actively participates with skilled interventions. Pt's temperature at 97 degrees.
biceps, triceps, deltoids, latissimus dorsi, trapezius, pectoralis major/minor, core musculature,
Pt little/no progress secondary to few treatment sessions. Pt little/no progress exhibited. Place on iso due to covid-19 pandemic.
Pt could not be accommodated with rehab tx schedule due covid protocol and conflict with nursing staff schedule.
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 required Max verbal/tactile cues to initiate task this date. Pt's temperature at 97 degrees.
decreased attention skills, moderate cognitive impairment and reduced problem solving skills. eliminate distractions, quiet location for treatment and use low stimulation environment for treatment.
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.
Documentation Blurbs
1. Patient will tolerate AE (appropriate splint to be assessed) x 1 hour with no redness or swelling to manage contracture to LUE.
7. Patient will decrease risk for falls as evidenced by an increase in score to 16 inches on Modified Functional Reach Test indicating no risk for falls.
9. Patient will increase functional ax tolerance to 1 hour in order to increase participation within environment and QOL.
14. Patient will decrease risk for falls as evidenced by an increase in score to 56/56 on the FIST Test.
18. Patient will safely perform functional activities of choice for 2 hours w/o falls in order to facilitate ability to live in environment w/least amount of supervision and assistance.
26. Patient will identify at least 5 positive effects of proper personal care on her mental and physical health independently.
27. Patient will select clothes and dress up safely w/minimal physical assistance after 5 sessions.
29. Patient will be able to communicate w/others adequately w/in 2 weeks.
30. Patient will demonstrate proper eye contact with the therapist while communicating with minimal verbal cues 3/5 attempts.
32. Patient will be able to communicate w/others adequately w/in 2 weeks.
34. Patient will develop high self-esteem and express herself positively after 2 weeks.
35. Patient will recognize and mention 5 of their strength and positive potential independently after 5 sessions.
36. Patient will finish a 15 minute cheerful activity and praise self independently w/in 5 sessions.
37. Patient will perform a previously enjoyed interest and develop a new one with minimal visual self-exploration cues after 1 week.
Ther Ax
12. Patient arrived at skilled OT complaining of 4/10 R shoulder pain limiting UE dressing tasks. Upon assessment, patient unable to raise RUE against gravity. Patient instructed in gravity eliminated reaching task on table top to increase R shoulder flexion, extension, horizontal abduction/adduction to improve ability for dressing tasks. OT provided intermittent tactile cues to reduce compensatory strategies and isolate targeted muscle groups needed for functional task. As patient's pain subsides, progress to against gravity reaching tasks next session.
16. Patient presents to skilled OT s/p fall in patient's bedroom resulting in L sided hip pain and overall weakness. Without OT, patient is at risk for further decline as patient lives alone and was I with all tasks. Due to L sided hip pain, patient having noted difficulty getting off low surface heights of bed. Patient instructed in variety of sit to stands, stands to sits from multiple surface heights to increase overall function. Patient required min A initially and was provided cues for technique including hand, feet, and trunk placement. By the 4th trial, patient was able to complete with supervision. Patient was also provided with pictorial handout providing adaptive equipment (bed risers) recommendations as a resource to heighten the bed to allow for smoother and less difficult transitions from his low bed if this continues to be an issue for him. Will require follow up next session to ensure independence.
21. Clinician provided minimum assistance while patient performed standing tolerance focused on picking up object on floor and placing on bedside table...
Manual Therapy
WC Sitting Tolerance - Tolerated sitting in wc x1 hour continuous without slipping and no signs of pain/discomfort in order to increase socialization opportunities and to reduce risk of pressure sores.
SPLINT adjustments - with required skilled positioning for effective application.
V/T to increase Participation - Therapist provided Max verbal/tactile cues to facilitate participation including redirection as needed secondary to decreased volition and arousal/alertness.
COVID Hall Patients - Pt positive for COVID-19; clinician implemented all infection control practices including use of PPE for droplet precautions during treatment session in room.
CONCURRENT - Patient participated in concurrent therapy with 1 other patient to successfully progress towards individual treatment plan/goals by addressing patient's gross motor coordination deficits, strength impairments, postural alignment/control and balance deficits; skilled interventions included.
RESPONSE TO SERVICES - actively participates with skilled interventions. compliant with skilled interventions and compliant with trained techniques.
BOLTs and SCREWS activity - Therapist provided FM activity to facilitate BIL hand dexterity and in-hand manipulation skills to increase ability to perform functional grasp/release of daily living items.
Standing Frame - Tolerated supported standing utilizing standing frame x8 minutes continuous with coaching for trunk righting and posture to reduce knee pain.
CONCURRENT - Pt participated in concurrent therapy with 1 other pt to successfully progress towards individual treatment plan/goals by addressing pts GMC deficits, strength impairments, postural alignment/control and balance deficits; pt worked on
RESPONSE TO SERVICES - Actively participates with skilled interventions. O2 saturation levels maintained at during today's session. Compliant with skilled interventions and compliant with trained techniques. Compliant with skilled interventions however with verbal/tactile redirection as needed secondary to aversion to non-preferred tasks.
V/T to Increase Participation - Therapist provided Max verbal/tactile cues to facilitate participation with redirection as needed secondary to decreased volition and arousal/alertness. O2 saturation levels maintained at
ISO Tx Session Completed - Pt implemented all infection control practices including use of PPE for droplet precautions during treatment session in room.
Fall prevention (call light with dementia) - Therapist educated patient on fall prevention strategies to correctly identify call light and implement usage by correctly answering yes/no questions with …….. at …….. with noted deficits with attention and emotion regulation (crying) impacting progress secondary to presence of dementia.