Click-to-copy neuromuscular re-ed documentation for OTs and COTAs in skilled nursing. Free, no login.
Patient will increase dynamic standing balance to Good using righting reactions 100% of the time in order to safely perform toilet/commode transfers with mod I.
Patient engaged in neuro reeducation techniques to increase dynamic standing balance via crossing midline bilaterally c arms at 90 degree shoulder flexion and full elbow extension in standing x 10 reps x 3 sets bilaterally. Patient demonstrates F-/G+ dynamic standing balance. OT instructed patient to widen stance to shoulder width for larger BOS (base of support), requiring verbal cues x 50% of time.
Patient engaged in ther ax to increase dynamic standing balance and GM/proximal strength via omnistand at level 2 (11 degrees in all planes). Patient's standing tolerance at 10 minutes before needing rest break. OT instructed patient to widen stance to shoulder width for larger BOS (base of support) and to take a step in order to increase righting reaction when patient feels as though he is falling, requiring verbal cues x 50% of time
E-stim, neuromuscular re-education protocol applied to LUE pressure points (web space between the thumb and index finger, lateral end of the transverse elbow crease when elbow is flexed, dorsal surface of the shoulder posterior and inferior to the acromion, and midway between the spinous process of c7 and the acromion) at 45 mA x 30 minutes.
13. In unsupported seated position, patient was instructed in dynamic reaching tasks to facilitate increased ability and improved balance to independently reach in her kitchen cabinets from w/c level. OT facilitated task to incorporate functional reaching in all planes using BUE to retrieve objects. Patient required min verbal cues and visual demo to initiate, CGA at times needed to maintain sitting balance. Most difficulty noted when reaching above 140 degrees in B shoulder flexion as muscles fatigued easily. OT provided tactile guiding to maximize performance and decrease substitution (lateral trunk flexion) to achieve optimal performance.
21. In standing, with unilateral upper UE support as needed, patient instructed in single stance tasks to facilitate improved standing balance while reaching for overhead items. Patient instructed in single leg raise while reaching for overhead items with initial max vc and tactile cues to illicit appropriate muscles to maintain balance as well as cues to maintain hips in neutral. Progressed patient this session to standing with no UE support; however, did require min A for proper balance recovery techniques when engaging in functional reaching (simulating reaching for grooming items in bathroom). Patient with min cues for posture to reduce trunk sway with standing tasks.
25. OT instructed patient in neuro reeducation techniques to increase dynamic standing balance via crossing midline bilaterally c arms at 90 degree shoulder flexion and full elbow extension in standing x 10 reps x 3 sets bilaterally. Patient demonstrates F-/G+ dynamic standing balance. OT instructed patient to widen stance to shoulder width for larger BOS (base of support), requiring verbal cues x 50% of time.
27. OT instructed patient in ther ax to increase dynamic standing balance and GM/proximal strength via omnistand at level 2 (11 degrees in all planes). Patient's standing tolerance at 10 minutes before needing rest break. OT instructed patient to widen stance to shoulder width for larger BOS (base of support) and to take a step in order to increase righting reaction when patient feels as though he is falling, requiring verbal cues x 50% of time
29. E-stim, neuromuscular re-education protocol applied to LUE pressure points (web space between the thumb and index finger, lateral end of the transverse elbow crease when elbow is flexed, dorsal surface of the shoulder posterior and inferior to the acromion, and midway between the spinous process of c7 and the acromion) at 45 mA x 30 minutes.
Therapist facilitated Proprioceptive Neuromuscular Facilitation (PNF) contract, relax and hold techniques to patients bilateral BUE deltoids to increase strength, tolerance and coordination for carryover to functional tasks such as UB dressing and oral hygiene. Pt required 25% verbal and tactile cues for sequencing of tasks. Therapist directed pt in reaching outside base of support during unsupported/supported sitting activity to increase trunk stability for carryover with transfers.
bilateral integration techniques and Neuromuscular Development Techniques (NDT) to facilitate crossing mid-line and facilitate patterned movements, joint compression to LUE x 15 seconds with clinician supporting elbow and wrist, D1/D2 patterns 3 sets of 10. Therapist directed pt in reaching outside base of support during unsupported sitting activity to increase trunk stability for carryover with transfers.
bilateral integration techniques and Neuromuscular Development Techniques (NDT) to facilitate crossing mid-line and facilitate patterned movements, joint compression to LUE x 15 seconds with clinician supporting elbow and wrist, D1/D2 patterns 3 sets of 10.
E-Stim applied to B shoulders and biceps for purpose(s) of to facilitate muscle contraction, strength, decrease risk of falls, coordination and muscle power and intensity level/settings at Neuro-Re-ed Triphasic PENS 38 mA x 15 minutes with skin integrity intact pre and post session.
E-Stim applied to R anterior/posterior deltoids, bicep and triceps for to facilitate muscle contraction, strength, decrease risk of falls, coordination and muscle power and intensity level/settings at Neuro-Re-ed Triphasic PENS 38 mA x 15 minutes with skin integrity intact pre and post session.
E-Stim applied to L thenar/hypothenar eminence, anterior/posterior forearm to facilitate muscle contraction, strength, decrease risk of falls, coordination and muscle power and intensity level/settings at Neuro-Re-ed Triphasic PENS 38 mA x 15 minutes with skin integrity intact pre and post session.
Patient participated in concurrent therapy with 1 other patient to successfully progress towards individual treatment plan/goals by addressing patient's balance deficits, ROM, gross motor coordination deficits and safety awareness deficits; skilled interventions included static/dynamic, sitting balance, therapeutic and aerobic exercises, and education on safety precautions.
Patient participated in group therapy with 2 other patients to successfully progress towards individual treatment plan/goals by addressing patient's balance deficits, BUE strength, gross motor and fine motor coordination deficits and safety awareness deficits; skilled interventions included static/dynamic sitting balance by reaching for objects from pt's reach to facilitate core strength, aerobic exercises and education on safety precautions to decrease risk of falls, increase FIST score to 38/56 and facilitate independence with LB dressing.
Patient participated in group therapy with 2 other patients to successfully progress towards individual treatment plan/goals by addressing patient's balance deficits, BUE strength, gross motor and fine motor coordination deficits and safety awareness deficits; skilled interventions included static/dynamic sitting balance by reaching for objects from pt's reach to facilitate core strength, aerobic exercises and education on safety precautions to decrease risk of falls, increase Modified Barthel Index to 50/100 and facilitate independence with UB dressing, LB dressing, oral hygiene and toilet commode transfers.
Pt Max A for supine to sit at EOB to increase static sitting balance and activity tolerance in order to facilitate increase time of out the bed and facilitate independence with ADLs. Pt able to sit upright with Max A from clinician to activate core strength. Pt able to tolerate sitting at EOB x 10 minutes with poor static sitting.
balance deficits, safety awareness deficits, decreased safety awareness, fine motor control deficits, gross motor coordination deficits, decreased ROM, decreased static balance and strength impairments.
Skilled interventions focused on crossing midline to facilitate independence in functional skill performance, balance activities during sitting and strengthening activities to increase functional task performance. Pt able to tolerate session well and able to maintain sitting balance during dynamic sitting activities.
Patient participated in concurrent therapy with 1 other patient to successfully progress towards individual treatment plan/goals by addressing patient's balance deficits, ROM, gross motor coordination deficits and safety awareness deficits; skilled interventions included static/dynamic, sitting balance, therapeutic and aerobic exercises, and education on safety precautions.
8. Patient presents w/impairments in balance and motor coordination/strength w/limitations in mobility. D/t the documented physical impairments and associated deficits the patient is at risk for further decline in function.
16. Patient will increase dynamic standing balance to Good using righting reactions 100% of the time in order to safely perform toilet/commode transfers with mod I.
1. Patient engaged in ther ax to increase dynamic standing balance and GM/proximal strength via omnistand at level 2 (11 degrees in all planes). Patient's standing tolerance at 10 minutes before needing rest break. OT instructed patient to widen stance to shoulder width for larger BOS (base of support) and to take a step in order to increase righting reaction when patient feels as though he is falling, requiring verbal cues x 50% of time.
9. In unsupported seated position, patient was instructed in dynamic reaching tasks to facilitate increased ability and improved balance to independently reach in her kitchen cabinets from w/c level. OT facilitated task to incorporate functional reaching in all planes using BUE to retrieve objects. Patient required min verbal cues and visual demo to initiate, CGA at times needed to maintain sitting balance. Most difficulty noted when reaching above 140 degrees in B shoulder flexion as muscles fatigued easily. OT provided tactile guiding to maximize performance and decrease substitution (lateral trunk flexion) to achieve optimal performance.
17. In standing, with unilateral upper UE support as needed, patient instructed in single stance tasks to facilitate improved standing balance while reaching for overhead items. Patient instructed in single leg raise while reaching for overhead items with initial max vc and tactile cues to illicit appropriate muscles to maintain balance as well as cues to maintain hips in neutral. Progressed patient this session to standing with no UE support; however, did require min A for proper balance recovery techniques when engaging in functional reaching (simulating reaching for grooming items in bathroom). Patient with min cues for posture to reduce trunk sway with standing tasks.
Neuromuscular Re-education
1. OT instructed patient in neuro reeducation techniques to increase dynamic standing balance via crossing midline bilaterally c arms at 90 degree shoulder flexion and full elbow extension in standing x 10 reps x 3 sets bilaterally. Patient demonstrates F-/F dynamic standing balance. OT instructed patient to widen stance to shoulder width for larger BOS (base of support), requiring verbal cues x 50% of time.
3. Clinician provided moderate tactile cues to patient during balance training on foam pad focusing on ankle strategy and somatosensory balance...
1. E-stim, neuromuscular re-education protocol applied to LUE pressure points (web space between the thumb and index finger, lateral end of the transverse elbow crease when elbow is flexed, dorsal surface of the shoulder posterior and inferior to the acromion, and midway between the spinous process of c7 and the acromion) at 45 mA x 30 minutes.
EOM/B dynamic sit for FIST - Therapist provided verbal/tactile cues to facilitate abdominal muscle activation to increase trunk control during static balance activities including anterior/lateral/posterior perturbations and functional reaching tasks while sitting EOB unsupported to improve core strength, dynamic sitting balance and righting reactions needed to increase score on the Function in Sitting Test.
Omni Stand - Pt participated with variable dynamic standing adjunct to reaching for objects in various heights/planes through use of Omnistand in order to increase standing balance/tolerance needed for ADLs.
Fall Prevention Protocol (Balance) - Balance Fall prevention protocol implementation: clinician instructed pt on dynamic sitting activities reaching to frontal plane for objects for increased postural control, core activation and righting reactions for reduced risk of falls.
Neuromuscular SITTING - forward reach, lateral reach, weight shift anterior and weight shift lateral in sitting, supported, 10 repetitions reps, 3 sets without resistance and fading verbal instruction and fading tactile cues / facilitation given due to compromised technique in order to facilitate motor control, facilitate patterned movements and provide corrective assistance for loss of balance.
Neuromuscular SITTING (TD) - forward reach, anticipatory reaction anterior challenge, anticipatory reaction lateral challenge and weight shift anterior, in sitting, supported, 10 repetitions reps, 2 sets without resistance and consistent / 100% verbal instruction and consistent / 100% tactile cues / facilitation and consistent / 100% physical assistance given due to compromised attention, coordination, range of motion, strength, technique and muscle tone in order to facilitate motor control and facilitate patterned movements.
Neuromuscular STANDING - forward reach, perturbation anterior, perturbation lateral, perturbation posterior, weight shift multi-directional, step forward, tandem stance and overhead reach, in standing, supported, 10 repetitions reps, 3 sets without resistance and fading verbal instruction and fading tactile cues / facilitation given due to compromised coordination and technique in order to facilitate motor control, facilitate patterned movements and provide corrective assistance for loss of balance.
Neuromuscular POSITIONING - facilitation of position in space and facilitation of postural control, in sitting, unsupported, 10 repetitions reps, 3 sets in order to facilitate motor control, facilitate patterned movements and provide corrective assistance for loss of balance.
Neuromuscular NEUROMUSCULAR REED - gross motor coordination techniques and postural control in order to facilitate motor control, facilitate patterned movements and provide corrective assistance for loss of balance.
EOM activities for TOILETING - Therapist provided verbal/tactile cues to facilitate abdominal muscle activation to increase trunk control during functional reaching tasks including to retrieve object from behind (object at midline, hands breadth posterior) while sitting EOM to improve core strength, dynamic sitting balance and righting reactions needed for toileting tasks.
EOM including STATIC balance - Therapist provided verbal/tactile cues to facilitate abdominal muscle activation to increase trunk control during static balance activities including anterior/posterior/lateral perturbations and functional reaching tasks while sitting EOM to improve core strength, dynamic sitting balance and righting reactions needed to increase score on the Function in Sitting Test.
PAINTING for G/H and Eating - Therapist provided verbal/tactile cues for increased strategy during therapeutic craft activity to paint picture within borders utilizing provided paint brush in order to improve FMC, eye-hand coordination, tool manipulation and VMI skills needed for eating and G/H tasks.
Reacher for LB dressing - Therapist instructed pt with use of AE (reacher) for LB dsg to compensate for pt decreased sitting balance and improve safety and I with dsg. Therapist provided v/v/t during therapeutic activity to retrieve needed item from floor utilizing reacher, while sitting in wc, in order to increase GMC, eye-hand coordination, tool manipulation and VMI skills to enhance safety and facilitate I with LB dressing.
Omnistand Ball Catch - Pt participated with variable dynamic standing adjunct to reaching for objects in various heights/planes through use of Omnistand in order to increase standing balance/tolerance and righting reactions needed for community ADLs.
NeuroMuscular SITTING wc - forward reach, lateral reach, weight shift anterior and weight shift lateral in sitting, supported, 10 repetitions reps, 3 sets without resistance and fading verbal instruction and fading tactile cues/facilitation given due to compromised technique in order to facilitate motor control and facilitate patterned movements.
NeuroMuscular SITTING TD - forward reach, anticipatory reaction anterior challenge, anticipatory reaction lateral challenge and weight shift anterior, in sitting, supported, 10 repetitions reps, 2 sets without resistance and consistent / 100% verbal instruction and consistent / 100% tactile cues / facilitation and consistent / 100% physical assistance given due to compromised attention, coordination, ROM, strength, technique and muscle tone in order to facilitate motor control and facilitate patterned movements.
NeuroMuscular STANDING - forward reach, perturbation anterior, perturbation lateral, perturbation posterior, weight shift multi-directional, step forward, tandem stance and overhead reach, in standing, supported, 10 repetitions reps, 3 sets without resistance and fading verbal instruction and fading tactile cues / facilitation given due to compromised coordination and technique in order to facilitate motor control, facilitate patterned movements and provided corrective assistance for LOB.
NeuroMuscular STANDING 2 - Static standing balance training initiated for weight shifting for COG over BOS for improved balance to decrease fall risk with initiation of standing. Therapist facilitated bringing hips forward and increased trunk extension for upright upper body posture. Pt initially required Max A for correction with implementation of use of mirror to enable self-correction. Pt able to reduce level of assistance needed for Mod A with this visual feedback.
NeuroMuscular Positioning EOM - facilitation of position in space and facilitation of postural control, in sitting, unsupported, 10 repetitions reps, 3 sets in order to facilitate motor control, facilitate patterned movements and provide corrective assistance for LOB.
FALL PREVENTION PROTOCOL (BALANCE) - Fall prevention protocol implementation: Clinician instructed pt. on dynamic sitting activities reaching to frontal plane for objects for increased postural control, core activation and righting reactions for reduced risk of fall.