Frequent Notes

Eval Note: The patient has consented to the telehealth visit and these services provided remotely by the therapist. The following interventions were delivered via telehealth. Pt consent was obtained and is documented according to facility policy. During the session the therapist was located in Westfield IN and the patient was located at Walker Place in Shelbyville, IN. Additional individual present for the evaluation was the PTA. Moderate complexity evaluation performed with indications of muscle weakness, unsteadiness on feet, impaired balance, and difficulty walking. Examination of body systems addresses B hips, B knees, B ankles, and core/ elements from body structure and functions, activity limitations and/ or participation restrictions including transfers, standing tasks, ADLs, and ambulation. Clinical decision making using standardized patient assessment instruments and/or measurable assessment of functional outcome of Berg Balance Scale, 30 seconds sit to stand, TUG, FRT, MMT and pain scale. Skilled Interventions: Decision making related to progression of treatment plan and goals. Focus on muscle strengthening, dynamic gait training, static and dynamic standing balance, activity tolerance, and safety awareness. Introduction of transitioning to manual w/c due to ambulation becoming more unsafe.Addition of wound care due to right malleolus due to pressure sore noted; good healing and no complications. Static and dynamic standing activities to progress balance recovery skills and decrease fall risk during transfers, positional changes, and when performing ADLs. Progress Note: The patient has consented to the telehealth visit and these services with provided remotely by the therapist. The following interventions were delivered via telehealth using Alinea. Patient consent was obtained and is documented according to facility policy. During this session, the therapist was located in Westfield IN, and the patient was located at McKay Manor (Shelbyville). Additional individuals present with the patient during the session include PTA. Re-assessment of goals and discussion of status completed for PR- The patient continues to present with decreased static and dynamic balance, decreased functional capacity, decreased safety awareness, deficits in proprioceptive abilities, difficulty walking, and strength impairments continuing to place pt at a higher fall risk and limit his functional mobility. Continued skilled PT services are necessary in order to analyze gait pattern, improve static dynamic balance, increase coordination, increase functional activity tolerance, increase independence with gait, increase LE strength, minimize falls and promote safety awareness in order to enhance patient's quality of life by an improved ability to decrease level of assistance from caregivers and facilitate increased participation with functional daily activities. Skilled PT sessions to additionally work on safety and independence with manual w/c mobility. Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: Falls, Further decline in function, and increased dependency upon caregivers.