Click-to-copy prom documentation for PTs and PTAs in skilled nursing. Free, no login.
HAMSTRING & HIP PROM: Patient received slow static stretching to BLE knee flexors and PROM to hips and knees in all planes.
PROM – ALIGNMENT – AAROM - Patient was progressed through PROM and stretching exercises to BLE in all planes with emphasis on increasing B knee ext ROM and R hip IR ROM for improved anatomical alignment and joint health. Effective handling techniques were identified for the development RNP and contracture management program as follows: calming, on-going verbal instructions and sustained pressure to antagonist musculature. Patient was lead through B knee ext/flex AAROM and repositioning in supine for improved self-repositioning and redistribution of pressure points in order to protect skin integrity.
PROGRESSED TO PROM - Patient was progressed through BLE PROM to B hips, knees, and ankles in all planes and B AAROM hip and knee extension and flexion in order to increase BLE ROM, improve joint health, and assist in the development of RNP with effective handling techniques. Techniques utilized in order to reduce tone and improve performance of exercises were calming verbal instructions and slow advancing in movement in order to not exacerbate spasticity.
PROGRESS TO PROM – HYPERTONICITY - In order to improve functional mobility, patient was progressed through PROM and stretching exercises to BLE to increase hip and knee ext. ROM and improve joint health. Effective handling techniques were monitored for the development of RNP and contracture management programs. Patient required soothing verbal instructions and gentle, rocking motion in order to facilitate gains in ROM, manage hypertonicity, and decrease guarding due to pain to ---.
PROM + STRETCH – STANDING – CGA TRANSFER – GAIT FT - Patient was progressed through PROM and stretching to B knees in order to increase knee ext ROM for improved standing posture and balance during stance phase of gait. Patient was coached through sit-to-stands in order to improve sequencing of activity and strengthen BLE extensor musculature for improved performance of functional transfers. Patient required CGA for transfer and tactile facilitation to B glutes and hamstrings in order to come to edge of seat and maximal verbal cueing for proper positioning of feet, trunk, and UEs in preparation for extension phase of sit-to-stand. Patient is demonstrating improvement during transfers with less need for manual A. Patient was able to ambulate x ----- feet with maximal tactile facilitation to ----- hamstrings for increased knee flexion in order to improve foot clearance and step length.
PROM KNEES - Patient was lead through PROM and stretching exercises to B knees in order to increase B knee ext ROM to improve upright standing posture and gait pattern. Patient responded well to exercises and demonstrates increased tolerance to exercises and motivation to increase knee ext ROM for improved standing and ambulation.
GENERAL PROM FOR RNP - Patient was progressed through BLE PROM and stretching exercises to hips, knees, and ankles in order to increase ROM with emphasis in making gains in R hip IR, R knee ext, and L knee ext ROM. Effective handling techniques were monitored for the development of RNP and for contracture management program. Patient responded well to on-going verbal instructions of exercises and slow, steady gains in ROM with maximal limb support.
Patient received PROM to B LE in all planes x --- reps in supine to maintain joint integrity and prevent contracture 2/2 decreased volitional movement. Slow sustained end range hold --- sec; no guarding noted.
Patient received PROM to R shoulder flexion, abduction, and ER x --- reps in supine within pain-free range to maintain ROM and prevent adhesive changes. Patient reported --- of 10 at end range.
Patient received PROM to L ankle DF x --- reps with --- sec sustained hold in supine to address --- degree PF contracture limiting foot flat in stance.
Patient received PROM to B hips in flexion, abduction, and ER x --- reps to maintain ROM for perineal care and dressing. Patient positioned in supine with --- precautions observed.
Patient received PROM to B knees x --- reps in supine to maintain --- degrees extension needed for standing and to prevent flexion contracture.
Patient received PROM to R elbow flexion and extension x --- reps with sustained low-load end range hold --- sec to address --- degree flexion contracture limiting hygiene.
Patient received PROM to B wrists and digits x --- reps to maintain tenodesis and prevent intrinsic tightness. Splint schedule reviewed with nursing.
Patient received PROM to B LE in supine x --- reps prior to positioning to reduce tone and facilitate w/c seating tolerance. Modified Ashworth --- at R quadriceps.
Patient received PROM to L shoulder in scapular plane x --- reps with scapulohumeral rhythm maintained to protect capsule following --- injury.
Patient received PROM to B ankles in DF, PF, inversion, and eversion x --- reps to maintain mobility for transfers and prevent skin breakdown at heels.
Patient received PROM to R hip in supine x --- reps observing posterior THA precautions with no hip flexion beyond 90 degrees, adduction past midline, or IR.
Patient received PROM to B LE x --- reps in R/L SL to accommodate --- positioning restriction and to promote circulation. No adverse skin or vascular response.
Patient received PROM to B UE x --- reps prior to donning splints to reduce tone and improve splint fit. Skin inspected before and after; no redness.
Patient received PROM to L knee flexion x --- reps to maintain --- degrees needed for w/c foot placement and sit to stand.
Patient received PROM to B cervical rotation and lateral flexion x --- reps within pain-free range to maintain head control for feeding and w/c positioning.
Patient received PROM to R shoulder x --- reps with scapular mobilization to reduce guarding prior to functional reaching. Patient tolerated with --- of 10 pain.
Patient received PROM to B hip and knee x --- reps in supine to reduce morning stiffness prior to bed mobility training.
Patient received PROM to L ankle with sustained --- sec hold and heel cord stretch x --- reps to preserve DF needed for RW ambulation.
Patient received PROM to B LE x --- reps with vitals monitored 2/2 --- ; BP --- and HR --- remained within parameters throughout.
Patient received PROM to R UE x --- reps in supine with scapular protraction to reduce shoulder subluxation risk 2/2 flaccid hemiparesis. Gap measured at --- fingerbreadths.
Patient received PROM to B digits x --- reps with individual MCP, PIP, and DIP isolation to prevent claw deformity and preserve grasp.
Patient received PROM to B LE x --- reps immediately following e-stim to capitalize on reduced tone. Modified Ashworth improved from --- to --- post session.
Patient received PROM to L hip abduction x --- reps to maintain ROM required for w/c seating symmetry and pressure relief.
Patient received PROM to B shoulders x --- reps in supported sitting to maintain ROM for dressing while accommodating --- positioning tolerance.
Patient received PROM to R knee extension with low-load prolonged stretch --- min via wedge to address --- degree flexion contracture.
Patient received PROM to B LE x --- reps prior to standing to improve tolerance to // bar standing. Patient tolerated --- min standing following.
Patient received PROM to L UE x --- reps with careful support at humerus and scapula to prevent impingement 2/2 --- degree subluxation.
Patient received PROM to B hips and knees x --- reps in supine to relieve stiffness reported by nursing during AM care. Nursing educated on positioning.
Patient received PROM to R ankle x --- reps with orthotic removed; skin inspected and found ---. Orthotic re-donned with nursing present.
Patient received PROM to B LE x --- reps with patient education on the purpose of ROM and encouragement to participate actively where able.