Click-to-copy transfers & mobility documentation for OTs and COTAs in skilled nursing. Free, no login.
Patient will perform shower chair transfers with … A w/o falls.
Patient will perform toilet/commode transfers with … A w/o falls.
OT instructed patient in increasing hip flexion during swing phase of gait in order to improve foot clearance when negotiating thresholds or uneven surfaces, requiring verbal cues 50% of time.
OT trained patient in improving safety with gait when negotiating thresholds while following visual cues.
Care plan held for patient. OT attended and informed staff and patient's daughter of patient's progress in therapy. OT informed persons in attendance of patient's decreased safety awareness with electric w/c.
Patient requires min/CGA for w/c <-> bed transfer. OT instructed patient in proper sequencing via scooting to EOB/wheelchair, leaning forward c nose over knees, and pushing off c UEs and safety precautions when transferring via making sure brakes are locked and using UEs for a controlled movement to guide self when perform stand to sit transfer.
Patient required mod A to perform bed <-> w/c transfer c sliding board x 10 sets. OT instructed patient in proper hand placement and activating core, using UEs to transfer via sliding board.
Patient engaged in functional mobility c hemi-walker x 50 feet x 2 sets c CGA/min A. OT instructed patient in proper use of hemi-walker c placement on dominant side, using hemi-walker in reciprocity to non-dominant side.
Patient engaged in ther ax to increase functional mobility and maneuverability c stairs via 4-step stairs x 5 to simulate stairs at patient's home. Patient completed stair climbing on 4-step x 5 c SBA x 3 sets c rest breaks and pulse, oxygen monitoring via pulse oximeter in between sets. Patient then simulated carrying groceries up stairs via holding 10 lb dumbbell whilst stair climbing on 4-step x 5 c SBA x 3 sets c rest breaks and pulse, oxygen monitoring via pulse oximeter in between sets. OT trained patient in improving safety with gait when negotiating thresholds while following visual cues.
28. Patient requires min/CGA for w/c <-> bed transfer. OT instructed patient in proper sequencing via scooting to EOB/wheelchair, leaning forward c nose over knees, and pushing off c UEs and safety precautions when transferring via making sure brakes are locked and using UEs for a controlled movement to guide self when perform stand to sit transfer.
32. Patient required mod A to perform bed <-> w/c transfer c sliding board x 10 sets. OT instructed patient in proper hand placement and activating core, using UEs to transfer via sliding board.
33. Patient engaged in ther ax to increase functional mobility and maneuverability c stairs via 4-step stairs x 5 to simulate stairs at patient's home. Patient completed stair climbing on 4-step x 5 c SBA x 3 sets c rest breaks and pulse, oxygen monitoring via pulse oximeter in between sets. Patient then simulated carrying groceries up stairs via holding 10 lb dumbbell whilst stair climbing on 4-step x 5 c SBA x 3 sets c rest breaks and pulse, oxygen monitoring via pulse oximeter in between sets. OT trained patient in improving safety with gait when negotiating thresholds while following visual cues.
Skilled interventions focused on training in log rolling technique to increase independence in bed mobility tasks. Clinician provided Max A to roll from side to side and from side lying to supine to decrease risk of pressure sore and maintain skin integrity.
Pt training in safety during transfers to carryover with toilet commode transfers. Pt required supervised A to transfer using standard walker. Pt required min verbal cues for proper hand/foot placement and leaning forward while pushing off bed to ease sit to stand and complete task.
Pt was given instruction with bed mobility to utilize log rolling techniques. Pt performed supine to sit at EOB and bed to wheelchair transfers with SBA and min cues for abdominal bracing to initiate task and proper hand/foot placement to increase safety with transfers.
W/C Mngmt: training in locking/unlocking brakes to facilitate safety and training in safe maneuvering through doorways.
W/C Mngmt: training in locking/unlocking brakes to facilitate safety.
W/C Mngmt: training in safely removing wheelchair arm / leg rests, training in locking/unlocking brakes to facilitate safety and instruction in maneuvering in small spaces.
Pt instructed in safety precautions during transitional movements to decrease fall risk and promote independence with functional transfers. Pt educated on UB dressing techniques to promote independence with ADLs with S/U to thread BUE through sleeves and pull garment overhead. Pt required additional time to perform sit to stand from EOB to wheelchair.
Clinician guided pt to floor secondary to pt's knees buckling during transfers. Charged nurse Alina was notified. Pt's temperature at 97.1 degrees.
Pt training in safety during transfers to carryover with toilet commode transfers. Pt required supervised A to transfer using standard walker. Pt required min verbal cues for proper hand/foot placement and leaning forward while pushing off bed to ease sit to stand and complete task.
max/TD+ for bed mobility tasks. unable to coordinated with nurse for due to unavailable this date.
9. Patient demonstrates significant decline in overall weakness, balance, activity tolerance is also very poor w/inability to perform bed mobility, sit to stand transfers and ambulation. Patient now w/foley catheter removed but refuses to assist w/getting up out of bed for fear of falling which can also increase risk of skin breakdown. Patient is dep A for all bed mobility, transfers, and functional mobility tasks as evidenced by 20 seconds on the 5 time sit to stand test or HIGH fall risk w/anxiety and fear of falling which compromises her safety during all mobility tasks at this time.
12. Patient will perform shower chair transfers with … A w/o falls.
13. Patient will perform toilet/commode transfers with … A w/o falls.
23. Patient will identify 3/3 fall prevention strategies with mod verbal cues, via verbal and/or return demonstration with 100% accuracy to reduce the risk of falls. Baseline: Max A 0/3 Ask for assistance during ambulating, Lock wheelchair, Footwear, obstacles, call light etc
2. Patient requires min/CGA for w/c <-> bed transfer. OT instructed patient in proper sequencing via scooting to EOB/wheelchair, leaning forward c nose over knees, and pushing off c UEs and safety precautions when transferring via making sure brakes are locked and using UEs for a controlled movement to guide self when perform stand to sit transfer.
3. Patient required mod A to perform bed <-> w/c transfer c sliding board x 10 sets. OT instructed patient in proper hand placement and activating core, using UEs to transfer via sliding board.
4. Patient engaged in functional mobility c hemi-walker x 50 feet x 2 sets c CGA/min A. OT instructed patient in proper use of hemi-walker c placement on dominant side, using hemi-walker in reciprocity to non-dominant side.
5. Patient engaged in ther ax to increase functional mobility and maneuverability c stairs via 4-step stairs x 5 to simulate stairs at patient's home. Patient completed stair climbing on 4-step x 5 c SBA x 3 sets c rest breaks and pulse, oxygen monitoring via pulse oximeter in between sets. Patient then simulated carrying groceries up stairs via holding 10 lb dumbbell whilst stair climbing on 4-step x 5 c SBA x 3 sets c rest breaks and pulse, oxygen monitoring via pulse oximeter in between sets. OT trained patient in improving safety with gait when negotiating thresholds while following visual cues.
4. OT facilitated muscle synergy of pelvic musculature for smooth movement control during the stand pivot motion in order to complete wheelchair <-> toilet transfers. Patient required minimal assist and 25% verbal cues for anterior hand placement providing tactile cues to maintain center of gravity and decrease fall risk.
Physical Therapy / Ambulation Notes
1. OT instructed patient in increasing hip flexion during swing phase of gait in order to improve foot clearance when negotiating thresholds or uneven surfaces, requiring verbal cues 50% of time.
2. OT trained patient in improving safety with gait when negotiating thresholds while following visual cues.
3. Clinician instructed patient to focus on short vs. long stride length, reduced velocity while ambulating on uneven surfaces in outdoor courtyard to reduce fall risk...
SIT TO STANDS - Therapist provided verbal/tactile cues to improve body mechanics/positioning and facilitate LE WB during training in sit to stand/stand to sit mobility with UE support utilizing parallel bars in order to enhance safety and increase I with LB dsg and transfers.
Transfers - Standard commode stand pivot transfers with UE support at Min A including verbal/tactile cues to improve body mechanics/positioning, facilitate LE WB and proper anterior/posterior stepping to facilitate pivot.
Sit to Stands Training - Therapist provided verbal/tactile cues to improve body mechanics/positioning and to facilitate LE WB during training in sit to stand/stand to sit mobility with UE support utilizing parallel bars in order to enhance safety and increase I with transfers and LB dressing.
Transfers (Stand Pivot) - Stand pivot transfers with UE support in 3/3 trials with Min A including verbal/tactile cues to improve body mechanics/positioning, facilitate LE WB and proper anterior/posterior stepping to facilitate pivot.
Transfers (WC to Commode) - Wc<>standard commode stand pivot transfers with UE support utilizing grab bars at Sup/T in 1/3 trials; verbal/visual cues to lock wc brakes and to facilitate proper wc positioning to increase efficiency, energy conservation and to reduce risk of falls.
Stand Pivot transfer Tactile cues for step - Stand pivot transfers with UE support at Max/Substantial A including verbal/tactile cues to facilitate upright head/neck and trunk posture and with tactile cues needed during stand pivot to facilitate initiation of RLE lateral side step.
Grasp/Release for DSG and bed mob - Therapist instructed pt in grasp/release therapeutic activities with R/L hand to increase I with dsg tasks and bed mobility. Facilitation provided using hand over hand assistance due to muscle weakness. Tx initiated with large items requiring full hand for grasp/release which pt demonstrated improved performance with but gradual decline with strength noted as size of items decreased. Unable to demonstrate performance of………….at this treatment.
RNP - RNP established with patient present to maintain current level of mobility and functional I level and to reduce risk of decline/complications. Duration 6x week x8 weeks x15 minutes.
RNP BED MOBILITY - Pt benefits from repositioning every 2 hours or as needed, to decrease risk of pressure sores.
W/C positioning and tolerance - therapist reclined w/c to increase anatomical alignment secondary to observed kyphotic posture with R lateral trunk flexion. Required reposition A secondary to excessive weight lateral shifting to the Right.