Click-to-copy progress & regression documentation for PTs and PTAs in skilled nursing. Free, no login.
Patient's functional performance is improving as a result of corrective stimulation being delivered with noted gains in LE motor control enhancing patients bed mobility skills, transfers, and ambulation with RW allowing patient to achieve PLOF of Supervised Assist with mobility.
Pt is demonstrating positive responses to the skilled interventions being delivered for improved functional performance with noted gains of gross motor muscle recruitment of BLE's, vertical balance with direct carryover into enhanced functional mobility that includes basic transfers, bed mobility, as well as progressed gait mechanics, allowing patient to achieve PLOF of Supervised Assist with mobility.
REGRESSION - Patient with noted regression this week; upon consultation with nursing and social services the pt has been identified with the following contributing factors 1) _________. Nursing communicated to MD and pt is now being treated with ___. With early medical intervention there the patient presents with positive prediction of recovery and continued progress as related to the previous rate and level of positive response to therapy intervention.
Patient demonstrates progress toward STG --- , improving ambulation from ---ft to ---ft with --- AD over --- sessions.
Patient demonstrates progress with TUG improving from --- sec to --- sec, approaching the --- sec goal and reduced fall risk threshold.
Patient met STG --- this date, achieving --- ; goal updated to --- to continue advancing toward the LTG.
Patient demonstrates a plateau in --- over the past --- sessions despite modification of --- ; PT will discuss with the PT for POC revision.
Patient demonstrates regression in --- , declining from --- to --- , attributed to --- . Nursing and MD notified.
Patient demonstrates progress with assist level reducing from --- to --- for transfers over --- sessions.
Patient demonstrates progress with the Berg Balance Scale improving from --- to --- of 56, moving out of the high fall risk category.
Patient's five times sit to stand improved from --- sec to --- sec, correlating with observed improvement in --- during functional tasks.
Patient demonstrates progress with standing tolerance increasing from --- min to --- min, supporting the goal of --- min.
Patient has not progressed toward STG --- ; PT identified --- as the barrier and modified the intervention to --- this date.
Patient demonstrates regression 2/2 an acute change in status including --- ; skilled PT placed on hold pending MD clearance.
Patient demonstrates progress with the 30 Second Chair Stand improving from --- to --- reps over --- weeks.
Patient demonstrates carryover of --- between sessions without cueing, indicating motor learning rather than session-limited performance.
Patient demonstrates progress with the 6MWT improving from ---ft to ---ft, an increase exceeding the MCID of --- ft.
Patient met LTG --- this date. PT will assess continued skilled need and initiate d/c planning with the interdisciplinary team.
Patient regressed in --- following a fall on --- ; interventions modified and fall risk re-assessed with a Berg of ---.
Patient demonstrates slower than anticipated progress; PT attributes this to --- and has adjusted the anticipated LOS to --- weeks.
Patient demonstrates progress with cueing reducing from --- percent to --- percent for --- , indicating improved independence.
Patient demonstrates progress toward LTG --- , now performing --- with --- assist compared to --- at eval.
Patient demonstrates regression in cognition affecting therapy carryover; PT recommends --- and has notified nursing.
Patient demonstrates progress with gait velocity improving from --- m/s to --- m/s, crossing the --- m/s threshold.
Patient demonstrates progress with pain decreasing from --- of 10 to --- of 10, permitting an increase in therapeutic exercise volume.
Patient's progress supports continued skilled PT; without intervention, the patient is at risk for --- and a decline to a lower level of care.
Patient demonstrates progress in --- but regression in --- ; PT has re-prioritized the POC to address --- this reporting period.