Click-to-copy functional mobility documentation for PTs and PTAs in skilled nursing. Free, no login.
Patient received bed mobility rolling training, PNF trunk core recruitment, and functional transfer training of sit to stands for improved ADL.
Patient is performing compensatory movement strategies addressing basic transfers and all phases of bed mobility.
Patient received bed mobility rolling training, and gross motor muscle facilitation for functional transfers in sit to stands. Patient also performed PNF core trunk muscles techniques for static sitting balance in w/c.
In order to improve participation in daily activities, patient was coached through supine-to-sit, bed to/from chair via stand-pivots, sit-to-stands, and static standing activities for improved bed mobility, transfers, and tolerance to ADLs. Patient required SBA with maximal visual and verbal cueing for safe and correct performance of all tasks. Patient was able to tolerate standing position for 1 minute before becoming tired and needing a rest break. Patient would benefit from continued PT for increased tolerance to functional WB activities and improved safety awareness.
Patient was lead through stand-pivot transfer from bed to WC and sit-to-stands at parallel bars in order to improve sequencing and tolerance to functional activities in bed mobility and transfers. Patient required mod A and max verbal cueing with one-step instructions in order to complete tasks safely and correctly.
In order to increase participation to daily activities in bed mobility, transfers, and toileting, patient was instructed through supine to/from sit, sit to/from stands, and transfers bed to/from WC for improved tolerance, sequencing, and dynamic balance during activities. Patient required part-to-whole technique for sit-to-stands for gradual progression to activity due to h/o dizziness during standing. Patient required maximal verbal cueing for improved safety awareness and correct performance of activities.
In order to improve bed mobility and upright functional mobility, patient was lead through supine-to-sit with mod A, stand-pivot transfers with mod A, and sit-to-stands with min A for improved sequencing of tasks, BLE functional strength, and dynamic postural control. Patient required maximal verbal, visual, and tactile cueing for correct and safe performance of tasks.
In order to improve independence in ADLs, patient was facilitated through functional activities in bed mobility via rolling, bridging, supine-to-sit, reaching to floor for donning of socks and shoes, and weight-shifting in all directions at edge of bed. Patient required SBA and minimal verbal/tactile/visual cueing for correct and safe performance of exercises. Patient was able to perform transfers WC to/from low and compliant surface (bed, sofa) safely and independently today.
Pt performed forward trunk flexion MAX A and lateral trunk flexion MAX A 3 sets x 10 reps in supine position to build abdominal strength to help improve trunk stability in order to participate in bed mobility activities with increased safety.
Pt performed forward trunk flexion MOD A 3 sets x 10 reps in sitting to build abdominal strength to help improve trunk stability necessary to participate in EOB activities with ease.
Pt performed forward trunk flexion MAX A and lateral trunk flexion MAX A 3 sets x 10 reps in sitting to build abdominal strength to help improve trunk stability in order to stand supported with equal weight distribution to decrease the risk for falls.
Therapist attended pt care plan meeting to assist in identifying possible modification and need for AE to improve pt participation and facilitate return to PLOF. Therapist identified need for -------. Provided family education on pt current status and goal to return to PLOF.
pt was provided repositioning stratigies in supine position to B LE to improve positioning to reduce risk for contracture and improve reciprical weight shifting stratigies.
pt participated in foward trunk flexion and lateral scooting activites to improve repositioning stratigies in order to participate in functional transfer activities safely with decrease risk for LOB.
Pt. performed foward trunk flexion 3 sets x 10 reps in sitting to build abdominal strength to help improve trunk stability in order to participate in supine <> sit activities with proper sequencing and foot placement necessary to decrease risk for falls
pt performed B t-spine rotation 3 sets x 10 reps in sitting to improve biomechanics with spinal rotation to take part in rolling activities in bed to decrease risk for skin breakdown.
Pt. requried VC/TC for proper sequencing with body mechanics
Patient ambulated ---ft from room to dining hall with RW at ---A to train functional distance required for meal attendance.
Patient performed w/c to sink transfer and standing at the sink x --- min to simulate the grooming sequence, requiring ---A.
Patient navigated ---ft through a crowded hallway with RW, requiring VC x --- for scanning and obstacle avoidance.
Patient performed functional mobility in the simulated apartment including bed, bath, and kitchen access at ---A over --- min.
Patient retrieved --- object from a --- inch shelf while standing at RW, requiring TC at pelvis to maintain BOS.
Patient retrieved --- object from the floor from standing at ---A, using a --- strategy without LOB.
Patient performed bed to bathroom mobility ---ft at ---A with education on call light use prior to unassisted attempts.
Patient ambulated ---ft with RW while carrying a --- lb object, simulating the load required for household tasks.
Patient performed toilet transfer and clothing management sequence at ---A with VC x --- for step order.
Patient performed shower entry over a --- inch threshold at ---A with grab bar use and education on wet surface hazards.
Patient ambulated ---ft on carpet and tile with transition training at ---A to prepare for the home environment.
Patient performed functional mobility with the elevator including call, entry, and exit at ---A with adequate timing.
Patient completed a simulated laundry task requiring ---ft ambulation and --- transfers at ---A over --- min.
Patient ambulated ---ft to therapy gym independently, then required ---A for the return trip 2/2 fatigue, indicating limited endurance.
Patient performed w/c mobility ---ft to the activity room and returned, demonstrating the endurance needed for facility participation.
Patient performed functional reach in standing to --- inches without LOB, an improvement from --- inches at eval.
Patient performed a simulated kitchen task with standing at counter x --- min and --- reaches at ---A.
Patient performed a --- step home entry simulation with a rail on one side at ---A, matching the reported home setup.
Patient ambulated ---ft with RW while opening and passing through --- doors, requiring VC for AD and door management.
Patient performed floor recovery training x --- reps at ---A to prepare for unassisted fall recovery at home.
Patient performed simulated night mobility with reduced lighting ---ft at ---A to address the reported nocturnal fall history.
Patient performed bed to w/c to bathroom sequence at ---A within --- min, reflecting the timing required for continence.
Patient ambulated ---ft with RW then completed a seated task, demonstrating the transition between mobility and function.
Patient performed medication retrieval from a --- inch cabinet while standing at ---A with VC for safe reaching.
Patient performed functional mobility with an ad lib route selection to assess problem solving and route planning at ---A.
Patient performed a simulated grocery task requiring ---ft ambulation with a cart at ---A over --- min.
Patient performed a curb and ramp sequence x --- reps at ---A to prepare for community reintegration.
Patient performed mobility with a hearing and vision check first, then ambulated ---ft at ---A, reinforcing the sensory pre-check habit.
Patient performed a mobility sequence with a distraction task; assist increased from --- to ---, demonstrating limited automaticity.
Patient performed functional mobility x --- min with a caregiver present; caregiver returned demonstration of guarding with --- accuracy.