Subjective / Objective — 72 Free Note Templates

Patient tolerated treatment for full session, demonstrating an intention to improve and progress with treatment. Patient required some rest breaks ---- with generalized low tolerance ----- but overall progressed through tasks well without complaint.

Patient continues to have deficits with strength, balance, coordination, safety and tolerance of standing tasks; which impact the patient's ability to perform functional mobility.

ROOM - Patient was returned to room and assisted back to bed; positioned properly with call button in reach. Nursing was made aware of patient positions and current status.

SEATED - Patient was placed in ------, sitting in wheel chair with breaks locked --- chair alarm in placed. Nursing was made aware of patient positions and current status.

Patient is demonstrating improved tolerance to sit-to-stands and gait as evidenced by less need for rest breaks and quicker pace in performance of activities. Oxygen saturation level at beginning and end of treatment was 95%.

Patient was alert and oriented x 1 (place, date) at beginning of session and progressed to oriented x 2 (date) at end of session. Oxygen saturation levels at beginning, during, and end of treatment were 97%, 98%, and 97%, respectively.

Patient tolerated treatment well and expressed motivation to come to sitting position in next treatment.

Patient presented with a productive cough during treatment without abnormal sputum; nurse reported him having cough episodes every now and then.

Patient reported feeling very weak and debilitated today and that he has not been eating regularly due to lack of hunger. Patient refused breakfast this morning. Oxygen saturation levels at beginning and end of treatment were 97% and 98%, respectively.

Patient reported significant feelings of anxiety and demonstrated distress mid-treatment due to back pain, anxiety disorder, and PTSD. Patient was given a break to breathe and bring anxiety level down before continuing.

Patient was positioned with pillows and wedges under trunk and BLEs in order to relieve pressure points and facilitate optimal circulation.

Patient's level of cognition appears to be improving indicating improved carry-over of learned tasks.

Patient is demonstrating decreased tolerance to standing position as evidenced by increased signs of exertion with increased chest expansions and reports of minimal dizziness. Oxygen saturation levels at beginning, during, and post treatment were 94%, 97%, and 95%, respectively.

Patient continues to report feelings of dizziness upon coming up to sitting and standing positions; however is demonstrating increased tolerance to upright positions.

Patient required rest breaks after each position change due to moderate symptoms of orthostatic hypotension.

Patient's BP was abnormally low at beginning of treatment (85/52 mmHg). Nurse was notified and patient was returned to bed positioned with legs elevated. Patient's BP was normalized to 120/69 mmHg within 10 minutes of lying down. Nurse reported that low BP may be due to patient being taken off peg tube feeding and progressed to bolus feeding, causing lower levels of fluid in the body. When treatment was resumed, remained within normal limits (115/66 mmHg).

Patient reported feelings of significant fullness and heavy sleepiness during treatment due to having eaten breakfast shortly prior to session. Patient requested therapy before breakfast or one hour after breakfast.

Patient tolerated tx well with no signs of distress/discomfort. Patient was cooperative throughout tx; however, impairments to cognition sometimes hinder effective therapist/pt. communication and correct performance of exercises.

Patient was cooperative and motivated to walk longer distances today. Patient tolerated tx well and did not report any distress/discomfort. VS and exertion level were closely monitored for patient safety.

Patient is demonstrating improvement as indicated by increased trunk/BLE strength, active participation during tx and increased tolerance to functional activities.

Patient demonstrates potential to reach goals as indicated by good participation and improved dynamic balance.

Patient demonstrates improvement in dynamic postural control in all activities performed today. Barrier for progress is significant pain to LLE and lumbar region due to sciatica and recent laminectomy; nurse was notified and patient was advised to take pain medication 45 minutes before therapeutic treatment for decreased pain and increased tolerance to activities.

Patient demonstrates potential for improvement as indicated by ability to follow multi-step instructions and good participation during treatment.

Patient tolerated tx well as indicated by increased tolerance and participation during treatment.

Patient is demonstrating improvement as indicated by increased independence during treatment and noted carryover of learned skills outside of skilled rehab.

Patient responded to tx well as indicated by good participation and tolerance to tx.

Patient demonstrated great participation today and is showing potential for improvement as indicated by increased functional activity tolerance.

Patient is demonstrating potential for improvement as evidenced by increased FIST score to 40/56. Patient continues to require extra time for initiation and performance of tasks.

Patient demonstrates good potential to reach goals as indicated by good ability to learn new information and minimal need for redirecting and cueing.

Patient tolerated treatment well and would benefit from continued PT to improve performance and tolerance to functional activities.

Patient tolerated treatment well as indicated by improved technique, tolerance, safety, distance, and balance during ambulation.

Patient was compliant with today's treatment, and would benefit from continued PT for improved strength and endurance in order to improve upright sitting for increased participation in ADLs.

Group Exercise Therapy: The patient participated in a group exercise therapy session, focusing on seated exercises targeting the quadriceps, calves, hamstrings, hip abductors, and hip adductors. The exercises were designed to enhance lower extremity strength, flexibility, and range of motion. The group therapy format was chosen to improve the patient's physical therapy tolerance, participation, and overall performance through socialization and peer support. During the session, patients were guided through a series of exercises, including seated marching, seated heel raises, seated leg curls, seated hip abduction and adduction, and seated knee extensions. The therapist provided instructions, demonstrations, and verbal cues to ensure proper technique and safety. Participants were encouraged to engage with one another, fostering a supportive environment that promoted motivation, accountability, and camaraderie.

Pt engaged in group LE strengthening exercise for increase hip knee and ankle strength for improved functional mobility and transfers. Seated resisted exercises for hip knee and ankle c AW c LAQs, hip abduction, marching, hip circumduction, sit to stands c use of deep breathing techniques to increase pt activity tolerance.

Room tx session was provided today to decrease risk of infection and transmission as per company isolation protocols this tx cycle. Pt did not have fever, coughing, nor SOB today. O2 sats: 99%.

Therapist attempted multiple times to assess for pt alertness and increase pt participation to skilled interventions with pt demonstrated decreased arousal with need for max VCs to increase pt alertness to task at hand. Noted change compared to pt last treatment sessions. Nursing aware and monitoring pt change for possible modifications.

Pt stated she felt increased fatigue and required extended rest this day.

Charge nurse awareness of pt presenting and change in alertness with need for monitoring.

Pt out of facility receiving HD treatment this day.

Pt sent out for altered mental status.

PT tolerated session with improved LE mobility and tolerance to WB activities this day with reduced foot discomfort.

Actively participates with skilled interventions and generalization of trained skills exhibited.

Patient reports --- of 10 pain at --- at rest, increasing to --- of 10 with activity. Pain described as --- and relieved by ---.

Patient oriented x --- ; follows --- step commands with --- percent accuracy. Requires VC x --- for safety awareness during mobility.

Patient reports sleeping --- hours last night with --- awakenings 2/2 --- ; fatigue reported at --- of 10 this session.

Vitals pre-session BP ---, HR ---, SpO2 --- percent on --- L O2. Post session BP ---, HR ---, SpO2 --- percent. No adverse response.

Patient demonstrates --- MMT at R hip flexors, --- at knee extensors, and --- at ankle dorsiflexors, limiting swing phase clearance.

AROM R shoulder flexion --- degrees, abduction --- degrees, ER --- degrees; all limited by --- and pain at --- of 10 at end range.

Patient c/o dizziness rated --- of 10 on transition to standing. BP supine --- and standing ---, consistent with orthostatic hypotension. Nursing notified.

Patient's spouse present and reports patient was independent with a SPC at PLOF and lived in a --- level home with --- steps to entry.

Patient reports goal of returning home with --- level of assist from ---. Goals reviewed and patient verbalized agreement with the POC.

Skin inspection of B heels and sacrum reveals --- ; findings communicated to nursing this date.

Patient exhibits --- edema at B LE with pitting grade --- ; girth measured --- cm at R and --- cm at L, --- cm above the malleolus.

Patient reports --- appetite and consumed --- percent of breakfast per nursing; endurance limited this session and attributed to intake.

Sensation intact to light touch at B LE except --- ; monofilament testing positive at --- sites on the R foot.

Patient demonstrates --- degrees DF at R ankle in knee extension and --- degrees in knee flexion, indicating gastrocnemius involvement.

Patient reports fear of falling rated --- of 10 and declined to release UE support during standing balance activities.

Patient's TUG measured --- sec this date, improved from --- sec at eval; remains --- the 13.5 sec fall risk threshold.

Patient's gait velocity measured --- m/s over 10 meters, --- the 0.8 m/s threshold associated with limited community ambulation.

Patient exhibits Modified Ashworth --- at R elbow flexors and --- at R plantarflexors, limiting positioning and orthotic fit.

Patient reports pain at --- is worse in the --- and improves with --- ; pattern consistent with --- and shared with the PT.

Patient scored --- of 56 on the Berg Balance Scale, indicating --- fall risk; primary deficits observed in items --- and ---.

Patient completed --- reps on the 30 Second Chair Stand, below the age-matched norm of --- reps.

Patient ambulated --- ft on the Six Minute Walk Test with --- rest breaks, improved from --- ft.

Patient's five times sit to stand measured --- sec, --- the 12 sec threshold associated with increased fall risk.

Patient reports --- percent adherence to the HEP and demonstrated --- of --- exercises correctly on recall.

Patient exhibits R shoulder subluxation measured at --- fingerbreadths with c/o --- of 10 pain during w/c propulsion.

Patient's weight bearing status remains --- on the R LE per MD order dated --- ; patient verbalized precautions with --- accuracy.

Patient c/o SOB rated --- of 10 on the modified Borg scale at ---ft ambulation, requiring a seated rest break.

Patient reports a fall --- days ago in the --- with --- injury; circumstances reviewed and contributing factors identified as ---.

Patient demonstrates --- percent step length symmetry with a decreased stance time on the R LE, consistent with an antalgic pattern.

Patient's PLOF was --- with the patient living --- and driving; current status is --- , representing a --- decline.