Click-to-copy goals & evaluation documentation for OTs and COTAs in skilled nursing. Free, no login.
Caregiver/patient will demonstrate 100% knowledge of home assessment recommendations as seen through return demonstration and feedback.
12. OT facilitated forward reaching activities at 90 degrees of shoulder flexion. Patient was given a 4 lb. on B wrists simulating item retrieval from shelves, placing the item on the floor and returning to the shelf. Patient performed the activity 10 x 1 set with reports of right anterior shoulder discomfort by the 7th attempt. Patient required 25% verbal and tactile cues to perform proper lifting technique following rotator cuff injury. OT graded the task after a 5-minute therapeutic rest break to then retrieve items at a 125 degree of shoulder flexion reaching. Similar discomfort was reported by the 4th trial. Patient educated on various pain relief techniques that patient could perform at home. Patient verbalized understanding.
24. Patient instructed in obstacle negotiation task to reduce falls during in home mobility item retrieval. OT facilitated weight shifting tasks in standing providing tactile guiding when needed (approx. 25% of the time). OT graded the task by incorporating distraction for scanning for items in environment. Patient had one instance of LOB requiring min A, but overall improvement noted. Continue to focus on high level mobility/standing tasks with scanning to reduce falls in the home during functional tasks.
Care plan meeting with pt and multidisciplinary team to report on pt's progress with POC goals and discharged planning.
Clinician attended care plan meeting with interdisciplinary team to discuss progress with therapy and recommendation for possible discharge home. Family/patient verbal understanding of OT recommendations.
RUE Roll Hand splint; pt. currently tolerating splint x3 hours; Goal to tolerate splint x5hrs daily. Restorative to preform skin checks before and after.
Increase technical wording, put actual joint and muscles. glenohumeral joint. % of cues and type of cues. Pain levels. % of deficits before and improvement after activity. Add which goal UB goals. Before/After. Assess their movements. External Oblique. Rectus abdominis.
Pt seen to measure progress toward POC this date. Pt able to perform toilet commode transfers at Max A using grab bar for support. Pt able to perform UB dressing with Mod A showing progress. Pt demonstrated increase Modified Barthel Index scored at 25/100.
Pt was instructed in safety during transitional movements in order to decrease fall risk and promote independence with UB dressing and toilet commode transfers. Pt able to dress UB with Mod A showing progress toward POC. Pt required Mod A to complete toilet commode transfers using grab bars showing progress toward goals.
Pt demonstrated S/U for UB dressing and Mod A for LB dressing this reporting period. Pt met goal of 15 minute activity tolerance this reporting period. Pt also demonstrated decrease pain of 3/10 during session this reporting period. Pt demonstrated 24/56 on FIST.
5. Patient verbally consented to visit. Virtual evaluation/therapy session performed using interactive audio/video technology to reduce risk of patient contracting COVID-19.
6. Patient verbally consented to telehealth visit. Virtual evaluation performed using interactive audio/video technology w/assistance of (name) to reduce the risk of patient contracting COVID-19.
Goals
6. Caregiver/patient will demonstrate 100% knowledge of home assessment recommendations as seen through return demonstration and feedback.
8. OT facilitated forward reaching activities at 90 degrees of shoulder flexion. Patient was given a 4 lb. on B wrists simulating item retrieval from shelves, placing the item on the floor and returning to the shelf. Patient performed the activity 10 x 1 set with reports of right anterior shoulder discomfort by the 7th attempt. Patient required 25% verbal and tactile cues to perform proper lifting technique following rotator cuff injury. OT graded the task after a 5-minute therapeutic rest break to then retrieve items at a 125 degree of shoulder flexion reaching. Similar discomfort was reported by the 4th trial. Patient educated on various pain relief techniques that patient could perform at home. Patient verbalized understanding.
20. Patient instructed in obstacle negotiation task to reduce falls during in home mobility item retrieval. OT facilitated weight shifting tasks in standing providing tactile guiding when needed (approx. 25% of the time). OT graded the task by incorporating distraction for scanning for items in environment. Patient had one instance of LOB requiring min A, but overall improvement noted. Continue to focus on high level mobility/standing tasks with scanning to reduce falls in the home during functional tasks.
Carrot tolerance - Pt. benefits from LUE Carrot x----; however, pt. benefits from interval assessment of carrot placement secondary to RUE pronation/spontaneous movement. Patient tolerated LUE carrot splint x3 hours however with 1 hour interval assessment of carrot placement secondary to spontaneous LUE movement including pronation.
FIST form STG set up - Patient will decrease risk of falls as evidence from increase in score to /56 on the Function in Sitting Test. Pt. benefits from ___ cueing/assist .... Just modify reps/assistance accordingly.
IADLs Light Maintenance Goal - Pt. will demonstrate increased independence with light home maintenance tasks to ______ without LOB, good safety awareness and WNL vitals to increased independence with IADLs.
Goal progression hindered by ISO - patient recently in isolation x14 days hindering patient progress with POC; however, patient contact precautions have been discharged and patient demonstrates good potential to return to PLOF as observed by emerging skills: ......... (fill in the blank with any good skills).