Click-to-copy peds documentation for PTs and PTAs in skilled nursing. Free, no login.
<patient> was seen for skilled Physical Therapy intervention focused on increasing trunk and core musculature strength, improve balance and coordination during transitional activities, decrease risks and incidences of falls and promote normal developmental pattern. Patient completed obstacle course such as walking on the 4 inch balance beam, walking on the foam line, walking on foam steps, and stepping over wooden obstacles with occasional HHA x 1 required due to occasional LOB. Overall, treatment was good.
<patient> was seen for skilled Physical Therapy intervention focused on increasing trunk and core musculature strength, improve balance and coordination during transitional activities, decrease risks and incidences of falls and promote normal developmental pattern. Patient was able to complete balance and coordination activities (various obstacles) such as walking on the 4 inch balance beam, walking on the foam line, walking on foam steps, and stepping over wooden obstacles with occasional HHA x 1 required due to occasional LOB. Patient required close SBA when kicking a moving ball due to occasional LOB during single-leg phase. No fall occurred during treatment. Overall, treatment was good.
The patient received skilled Physical Therapy intervention aimed at improving trunk and core musculature strength, enhancing balance and coordination during transitional activities, reducing the risk of falls, and promoting a normal developmental pattern. During the treatment session, a variety of activities were performed, including walking on a 4-inch balance beam, navigating a foam line, stepping on foam steps, stepping over wooden obstacles, using a treadmill, playing hopscotch, and engaging in single-leg stance (SLS) throwing and catching exercises. These activities challenged the patient's balance and coordination skills, with occasional assistance from a home health aide (HHA) needed for stability during certain tasks due to occasional loss of balance (LOB). Importantly, no falls occurred during the treatment session. Overall, the patient demonstrated positive progress, showing improvements in trunk and core strength, balance, coordination, and the ability to perform dynamic tasks involving SLS throwing and catching.
<patient> was able to focus better in therapy today. COVID19 PRECAUTIONS: Hand washing, face mask and body temperature check.
<patient> tolerated treatment well. Continue with current plan of care as per supervising PT. Alteration may occur when needed. <pta>, PTA. Supervising Physical Therapist: <pt>, P.T., DPT
Plan of care includes therapeutic exercises to improve mobility of trunk and bilateral lower extremity musculature; postural training to improve postural awareness and orientation; manual therapy; heat modality (PRN); balance and coordination exercises to improve gait skills; and patient education to train on home exercise program. Assessment findings and recommendations including frequency and duration of treatment were discussed with patient's mother who verbalized understanding and agreement. Alteration may occur when needed. <pta>, PTA. Supervising Physical Therapist: <pt>, P.T., DPT
Patient performed developmental play activities in prone x --- min to promote head control and antigravity extension. Caregiver present and educated on tummy time.
Patient practiced transitions from sit to quadruped x --- reps with TC at pelvis to facilitate weight shift and rotation.
Patient performed supported standing at the activity table x --- min to build LE weight bearing tolerance and encourage midline UE play.
Patient practiced cruising along furniture ---ft x --- reps at ---A to develop lateral weight shift and hip abductor control.
Patient performed reciprocal creeping ---ft x --- reps to promote trunk rotation and cross-body coordination.
Patient ambulated ---ft with a posterior walker at ---A; VC provided for step length and cadence.
Patient tolerated standing in the stander at --- degrees x --- min to promote bone density and hip joint development.
Patient performed AFO donning and doffing with caregiver return demonstration; caregiver verbalized skin checks with --- accuracy.
Patient practiced stair negotiation with --- steps using a rail at ---A with a step-to pattern, progressing toward reciprocal.
Patient performed sitting balance activities on a therapy ball x --- min with reaching for preferred toys to elicit righting reactions.
Patient performed transitional movement from supine to sit x --- reps with TC to facilitate the segmental pattern.
Patient participated in obstacle course activities x --- min to challenge motor planning, requiring VC x --- for sequencing.
Patient performed weight bearing through B UE in quadruped x --- min to improve proximal shoulder stability for fine motor tasks.
Patient practiced single limb stance x --- sec B during play activities to develop the stability needed for stair negotiation.
Patient performed jumping with B feet leaving the ground x --- reps, achieving --- of --- successful attempts.
Patient practiced ball kicking x --- reps to develop single limb stance and eye-foot coordination.
PT educated caregiver on positioning to reduce plagiocephaly risk; caregiver returned demonstration with --- accuracy.
Patient performed serial casting check; skin inspected and found --- , cast intact. DF measured --- degrees, improved from ---.
Patient performed gait training ---ft with an anterior walker in the school hallway to promote carryover to the educational setting.
Patient tolerated PROM to B LE x --- reps within pain-free range; caregiver educated on the home stretching program.
Patient performed pull to stand at the couch x --- reps at ---A, demonstrating improved LE extensor control.
Patient practiced navigating a --- inch curb x --- reps at ---A to promote community participation.
PT reviewed the plan of care with the caregiver and school team; goals updated to reflect --- and all parties verbalized agreement.
Patient performed play-based therapeutic activity x --- min; PT graded the task by --- to maintain engagement and challenge.