Click-to-copy evaluation documentation for PTs and PTAs in skilled nursing. Free, no login.
RESIDENT - Order received, Chart reviewed and assessment performed. See IE for details.
NEW - Obtained subjective history including past medical history and precautions, assessed for levels of transfer and gait. Patient responded well to initial evaluation and treatment. Patient does have a low tolerance to activities that will have to be improved, but was able to tolerate the full session. Discussed with patient (AND WHO) the impairments present that are impacting functional mobility and ADL. Educated patient (AND WHO) on the purpose of Skilled Physical Therapy and the responsibility of the patient to participate with in task to address deficits. Established and discussed LTGs and POC. Patient agreed to participate in skilled PT and did not have any remaining questions on the LTG or POC.
Patient evaluated this date following admission for --- . PLOF was --- ; current functional status is --- , representing a measurable decline warranting skilled PT.
Evaluation completed. Primary impairments include ---, ---, and --- , which directly limit --- and place the patient at --- fall risk.
Evaluation reveals --- MMT at B LE, --- degrees DF, and a TUG of --- sec, supporting the need for skilled intervention to restore safe mobility.
Patient evaluated with Berg Balance Scale scoring --- of 56, indicating --- fall risk. STGs and LTGs established with the patient and reviewed for agreement.
Evaluation completed with the patient and --- present. Home setup reported as --- with --- steps to entry and --- available for assist.
Patient demonstrates rehab potential rated --- based on prior function, cognition scored ---, motivation, and family support.
Evaluation identifies a --- deficit as the primary barrier to d/c home; PT recommends --- x --- per week for --- weeks.
Patient evaluated; d/c recommendation at this time is --- with --- level of assist, pending progress toward the established STGs.
Evaluation reveals --- WB precautions per MD order dated --- ; patient verbalized precautions with --- accuracy.
Patient evaluated with a 6MWT distance of ---ft, indicating --- endurance and supporting the goal of ---ft.
Evaluation completed; patient requires --- for bed mobility, --- for transfers, and --- for ambulation of ---ft.
Patient evaluated and screened for --- ; findings of --- were communicated to nursing and MD this date.
Evaluation reveals cognition adequate for --- step commands with --- percent carryover between sessions, supporting the potential for skilled training.
Patient evaluated; anticipated LOS is --- weeks based on current status, rate of progress in prior episodes, and comorbidities including ---.
Evaluation completed. Patient goals include --- ; these were incorporated into the POC and patient verbalized agreement.
Patient evaluated with a 30 Second Chair Stand of --- reps and a five times sit to stand of --- sec, both below age-matched norms.
Evaluation reveals --- edema, --- sensation, and --- skin integrity at B LE, each factored into the intervention plan.
Patient evaluated; prior therapy episode ended --- with the patient at --- level. Current decline is attributed to ---.
Evaluation completed and POC established for therapeutic exercise, gait training, neuromuscular re-education, and therapeutic activity as indicated.
Patient evaluated; skilled PT is medically necessary given --- , and the complexity of the interventions requires the skills of a licensed therapist.