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Student’s Name:
Andrea Strickland
Date: 5-24-14
SLCC Physical Therapist Assistant Program
Patient’s Initial Evaluation Homework Assignment
Initials of Patient (1 point): JC
Date seen by Physical Therapist (1 point): 5-16-14
Age (1 point): 59
Diagnosis (Including DOI, DOO or DOS) (3 points): Generalized muscle weakness and difficulty in walking following CABG surgery, Coronary
atherosclerosis of VE
Medications (2 points): Atorvastatin, Lantus, acetaminophen, Metoprolol Tartrate, Losartan Potassium, Effient, Amlodipine Besylate,
Lamotrigine, Omeprazole, Levothroid, Hydrocodone, Humalog.
Medical Issues (past and present) (2 points): pt is at risk for cardiac insufficiency, compromised general health, falls, and further decline in
function, CABG. Hx, CAD, type II DM, HTN, hyperlipidemia, chronic kidney disease, and seizure disorder.
Pertinent information
obtained from chart
review entered by
Physical Therapist
during “Patient’s Initial
Evaluation.”
(Medicare #: 97001)
Total: 40 points
1. Range of Motion Measurements: RLE=WFL, LLE=WFL (this was all that was stated in initial eval, there are no
goniometric numbers).
2. Manual Muscle Test (MMT): RLE strength = 4/5, LLE strength = 4/5.
3. Additional Data Collection: Respiratory status = WFL, Skin Integrity= redness in some areas, no edema, intact sensation,
intact visual spatial perceptual skills.
4. Bed Mobility (Move up and down in bed, supine<>EOB, etc): SBA ( all that was specified in chart)
5. Transfers (Sit<>stand, bed<>w/c, w/c<> mat, etc): CGA which includes stairs, W/C N/A
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6. Sitting: Static sitting = Good, Dynamic sitting = Good (maintains balance w/o support against mod resistance)
7. Standing: Static standing = Fair ( maintains standing balance 1-2 min w/o UE support w/o LOB). Dynamic standing = Fair( Min (A) or UE support to stand w/o LOB & reach ipsilaterally; unable to weight shift)
8. Ambulation/Stairs: CGA with stairs, Gait = CGA; distance level surfaces 150 ft w/ FWW. Uneven surfaces CGA 5 ft. w/
FWW. Pt exhibits forward
9. Special Tests: None specified in chart
Patient’s Goals: “I would like to get back to walking, community mobility, and household chores”.
Short Term Goals (5 points):
1) Pt will increase dynamic standing balance to G-/F+ spontaneously righting self when needed and w/o LOB and w
good safety awareness in order to reduce the risk for falls and improve ability to safely ambulate w/in
environment (Target 5/29/14)
2) Pt will safely ambulate on level surfaces 350’ using FWW w/ supervised (A) w normalized gait pattern and with
functional dynamic balance 90% of the time with reduced risk for falls and w/o SOB to increase independence w/
all functional ambulation (target 5/29/14).
3) Pt will safely perform functional transfers w/ supervised (A) w/ good safety awareness and w/o signs/symptoms of
physical exertion in order to return to prior level of functional abilities (5-29-14).
Long Term Goals (5 points):
1) Pt will safely ascend/descend 12 stairs w/ supervised (A) using handrails bilaterally for use of energy conservation
techniques w/o SOB (Target 6-12-14).
2) Pt will increase ability to safely ambulate Unlimited Distances within the community using least restrictive assistive
device w/ Supervised (A) w/ reduced risk for falls w/o SOB (Target 6-12-14).
Physical Therapist’s Plan of Care/Planned Interventions (10 points):
1) Neuromuscular reeducation (97112) to improve standing and dynamic balance
2) Gait training therapy (97116) to improve ambulation w/ assistive devices
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3) Therapeutic Activities (97530) to get pt back to previous level of function
4) Therapeutic exercises (97110) to strengthen and improve all functional abilities
Student Analysis of
Physical Therapist’s
Information
Contraindications (i.e. movement precautions, aspiration history and head must be 35 degrees or higher in supine
position, etc) (3 points): Sternal precautions, so pt cannot push down on walker to stand or lift more than 5#, etc. HTN,
need to take vitals and allow pt to rest when needed, sensation loss in feet.
Safety Considerations for the Patient (i.e. cardiac history, aspiration with clear fluids, pacemaker, atrial fibrillation,
dementia, COPD, on supplemental O2, etc.) (5 points): HTN, diabetes, cardiac hx, and seizure disorder.
Additional Information Needed and Rationale (MMT, ROM measurements, etc.) (4 points): MMT and ROM were taken to
evaluate if pt had normal measurements in LE’s to accomplish goals. 0/10 pain scale at rest and w/ movement
Functional Problem List (10 points):
1. Pt requires FWW during ambulation w/CGA
2.Pt has bil LE strength at 4/5 influenced by general muscle weakness
3. Pt has a “fair” static and “fair-“ dynamic standing balance, unable to weight shift
4. Pt has deficits in safety awareness, gait, and activity tolerance
5. Pt is at risk for falls
Questions for Physical Therapist Related to Initial Evaluation (5 points):
1. Why was there no numbers for the goniometric measurements?
2. Why was there no special tests administered to evaluate the LE muscles?
3. Why does the MMT just say RLE or LLE strength, instead of specific muscle groups?
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4. Why was a FWW selected because the pt is on sternal precautions?
Equipment Considerations (3 points): Gait belt for ambulation and transfers, FWW, pulse oximeter
SLCC Physical Therapist Assistant Program
Weekly Patient Progress Note Assignment
Daily Treatment Notes for Week (25 points/daily note, total of daily notes/number of daily notes= average out of 25 points):____________
Date: 5-21-14
Change of orders by doctor: None
Contraindications: None
Precautions: Sternal precautions, no lifting over 5#, HTN, fall risk
Patient’s medical status: Unchanged
S: Pt stated that he was feeling great with no pain and anxious about his discharge because he had to move within the next couple weeks.
O: Pt, PTA, and SPTA attended a POC meeting at the beginning of tx to discuss therapy, to see if pts goals were being met and to see about a
discharge date which was not stated at meeting. After meeting pt did ambulate with FWW around facility with CGA. A Balance Berg Test was
administered with an overall score of 37/56 to get a better understanding of balance deficits and what needs to be focused on during therapy. Pt
did need UE support during balloon toss activities when he would lose his balance, especially when his feet were together (decrease BOS)
w/CGA. 0/10 pain scale through tx.
A: Pt did well during balance activities but did require UE support in case of LOB. Most of pts tx was in a POC meeting where therapy and other
issues were addressed with facility representatives. Balance Berg Test score of 37/56.
P: Pt needs to continue to work on balance and safe ambulation around facility with FWW so he can return to previous level of function.
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Problem(s) encountered by SPTA and outcome(s): Only issue is that I do not have a previous tx to compare this tx with.
Changes that need to be communicated to PT/nurse: Pt did communicate with PT about being able to ambulate around facility w/ FWW
independently.
Date: 5-22-14
Change of orders by doctor: None
Contraindications: None
Precautions: Sternal precautions, no lifting over 5#, HTN, fall risk
Patient’s medical status: Unchanged
S: Pt stated that he was feeling good and ready for therapy before tx. He also stated that his standing tolerance is not that good.
O: Biodex for 20 min w/ resistance of 10. After 5 min of tx pt complained of pain in the R knee and the resistance was dropped to 0. MHP to R
knee with 5 layers of towels, 15 min, and mild, blanchable erythema noted after tx. Pain scale 7/10 before MHP and 4/10 after tx. Pt did require
approximately 6 rest breaks during Biodex tx, RPE 11/20, and SOB 3/10. Dynamic Gait Index test issued after ther ex with a total score of 17/24
(predictive of falls in the elderly). Pt required a FWW during all tests and used bil hand rails during stair test. Pt did bean bag toss in modified
tandum stance requiring UE support within reach in case of LOB and CGA. Pt did sway but did not rely on UE support.
A: Pt did progress balance exercises to a modified tandum stance w/o relying on UE support. Pt does need to work on cardiopulmonary
endurance to facilitate function and return to previous level of function. Safety was emphasized during ambulation including sternal precautions.
Dynamic Gait Index score of 17/24 which is an increased risk for falls.
P: pt will continue w POC to facilitate independence in community activities and potentially for discharge.
Problem(s) encountered by SPTA and outcome(s): none
Changes that need to be communicated to PT/nurse: none
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Date: 5-23-14
Change of orders by doctor: None
Contraindications: None
Precautions: Sternal precautions, no lifting over 5#, HTN, fall risk
Patient’s medical status: Unchanged
S: Pt stated he was feeling well and that there was no pain in his right knee today. He was wondering about discharge which he was told to talk
to the PT.
O: Biodex for 20 min requiring 4 rest breaks, 0 resistance. Gait training with FWW, CGA emphasizing safety awareness inside and outside the
facility. CGA during stair training to prepare pt for discharge and to use stairs at home. Pt did need verbal cues to keep all of the right foot on
the step for safety reasons. Vitals were taken after each set of ascending/descending stairs. Pt required UE support to complete balance
training tasks while standing on foam. Balance activities were to facilitate ankle and hip strategies to help right self and fall prevention. Pt
participated in LE strength activities, mini squats 2*10 sets. Pt was unable to complete total number without rests d/t fatigue in quads. 0/10
pain scale.
A: Pt tolerated ther ex with less rest breaks then previous tx. O2 sat rates did stay above 90% before and after each exercise. Pt reported no pain
in right knee during tx. Pt does require CGA during all ambulation and stair training and does need verbal cues to remember safety precautions
and keep proper posture.
P: Continue with POC, strengthening, balance, and gait activities to return to previous level of function and increase activity tolerance.
Problem(s) encountered by SPTA and outcome(s): None
Changes that need to be communicated to PT/nurse: None
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Summary of Weekly Patient Progress Note(s)
Rationale for Daily Plan of Care (75 points):
*Note: Summarize daily treatment notes within each square.
Modalities Used: hot
pack on right knee to
decrease pain.
Why Selected? The hot pack
was selected because the pt
could ride the biodex while
receiving pain tx.
Outcome(s): Pt reported a 7/10
pain scale before tx and it dropped
to 4/10 after hot pack.
Progression (If no change, why?) modalities
could be adjusted according to pts pain. But
since the pt only had the hot pack one day out
of the week I did not see a reason for trying
another pain modality.
Therapeutic Exercises
(Medicare # 97110):
Why Selected (muscle exercise
directed to and why)?
Provided Outcome(s):
Explain Progression (If no change, why?)
1. mini squats
1. mini squats was used to
strengthen the quads because
we noticed LE weakness as pt
was ascending/descending
stairs.
1. pt was unable to complete the
total number of reps given and
required a rest to complete task.
1. pt did not progress because he could not
complete the reps w/o taking a rest.
2. biodex to increase activity
tolerance and strengthen LE’s.
2. pt is slightly progressing endurance as he
started taking less rests in the last tx compared
to the first tx.
2. biodex
2. biodex was used at the
beginning of each tx as a warm
up
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Neuromuscular Activities
(balance activities for
sitting, standing, etc.)
(Medicare # 97112):
1. Dynamic Gait
Index
2. Berg Balance Test
3. Standing balance
activities
Therapeutic Activities
(Bed mobility and
transfers that includes
assistive device if
needed, assistance
required, etc.)
(Medicare # 97530):
1. Transfers from
exercise
equipment and
mat table to
FWW w/ CGA
Gait (Include assistive
device(s) if used, level of
assistance needed,
distance, gait
abnormalities, etc.)
(Medicare # 97116):
Gait w/ FWW and CGA
during therapy (pt
Why Selected?
1. Dynamic gait was
selected to see if pt
was at risk for falls
2. Berg Balance was also
selected for fall risk
3. Standing activities to
test dynamic balance in
different surfaces and
pertabations
Why Selected?
1. To improve transfer
activities w/ FWW and
teach safety measures
during the activities
Provided Outcome(s):
1. Test results 17/24. Pt does
have the chance for falls
2. Test results 37/56. Pt does
have the chance for falls
3. Standing balance did
challenge pt and help him
learn some ankle strategies
to right himself and help LOB
Provided Outcome(s):
1. To improve transfers from
CGA to SBA then complete
independence for
discharge
Progression and Why?
1. No progression (test)
2. No progression (test)
3. Pt did progress from the floor to foam.
He did need UE support and always
required CGA for safety reasons.
Progression and Why?
1. As patients LE strength and activity
tolerance improve, he will be able to
progress to the least restrictive device
safely and only use one hand rail on the
stairs.
Why Selected?
Provided Outcome(s):
Progression and Why?
FWW was selected because it
has the most UE support and to
prevent falls. Pt does need to
The better the pt ambulates with
the FWW, he will be able to
progress to the least restrictive
Pt can already ambulate for unlimited
distances. Quad cane training should be the
next step.
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requested to be able to
ambulate w/ FWW w/o
assistance around the
facility, the PT gave
approval). Pt can
ambulate unlimited
distances
remember his sternal
precautions.
device which is a long term goal.
Other: None
Why Selected?
Provided Outcome(s):
Goals Met (3 points):
Date Accomplished:
1. N/A
1. . N/A
2.
3.
2.
3.
New Goals Initiated (3 points):
Date Initiated:
1. N/A
1. . N/A
2.
2.
3.
3.
Progression and Why?
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Interventions that were beyond scope of work or knowledge as a SPTA (2 points): None so far.
SLCC Physical Therapist Assistant Program
Weekly Patient Progress Note Assignment
WEEK 2
Daily Treatment Notes for Week (25 points/daily note, total of daily notes/number of daily notes= average out of 25 points):____________
Date: 5-26-14
Change of orders by doctor: None
Contraindications: None
Precautions: Sternal precautions, no lifting over 5#, HTN, fall risk
Patient’s medical status: Unchanged
S: Pt stated he was feeling well and reported no pain. Pt did state that he could have worked harder during the ex. Pt also stated that he had
visual deficits during outside ambulation d/t sun glare.
O: Biodex, 20 min, no resistance, 3 rest breaks, SOB scale 3/10 and PRE scale 11/20 to improve LE strength and endurance. Pt required CGA
during ambulation w/ FWW and on stairs. Pt required a few VC’s to keep right foot entirely on each step on the descend. Pt demonstrated a
marked time pattern while ascending the stairs. Pt required multiple VC’s to keep in a straight line and to avoid obstacles while ambulating
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outside the facility. Pt ambulated 150’, 175’, 200’, 350’, requiring rest breaks between distances for approximately one minute d/t fatigue.
A: Pt did progress during on the Biodex bike requiring less rest breaks compared to previous tx. Pt did not progress on the stairs because he
marked time on the ascend when he previously used one foot per step.
P: Continue w/ POC and pt education about safety while ambulating in the community and avoiding obstacles.
Problem(s) encountered by SPTA and outcome(s): None
Changes that need to be communicated to PT/nurse: None
Date: 5 27-14
Change of orders by doctor: None
Contraindications: None
Precautions: Sternal precautions, no lifting over 5#, HTN, fall risk
Patient’s medical status: Unchanged
S: Pt stated that he was feeling well and had no pain, but that he wasn’t feeling well earlier on in the
morning. He is very anxious for discharge.
O: Pt required CGA-mod A during inside and outside gait training w/ FWW for safety reasons and to
help with pts LOB over uneven ground. Pt was able to go 250’, 250’, 200’, and 350’, pt required one
minute rests between each distance d/t fatigue. Biodex, 20m min, resistance 3, PRE scale 10/20, SOB
scale 3/10 to improve LE strength and increase activity tolerance. Dynamic balance activities to
facilitate proper standing posture and emphasize balance on uneven terrain, also to use ankle/hip
strategies while on uneven ground during dynamic activity. Pt required CGA- mod A during balance
tasks which he demonstrated frequent LOB, especially when bending over to pick up objects off the
grass.
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A: Pt did progress resistance on Biodex, but then needed more rest breaks than previous tx, and had
muscle cramps in his calves. Pt did progress to an unstable surface to do balance activities which
required mod A to keep him from falling.
P: Continue w/ POC and working on balance activities on uneven ground. Pt should wear sun glasses
while ambulating outside to help w/ visual deficits. Pt should continue ther ex to improve
cardiopulmonary endurance and LE strength.
Problem(s) encountered by SPTA and outcome(s): None
Changes that need to be communicated to PT/nurse: None
Date: 5-28-14
Change of orders by doctor: None
Contraindications: None
Precautions: Sternal precautions, no lifting over 5#, HTN, fall risk
Patient’s medical status: Unchanged
S: Pt stated that he was feeling better than he did yesterday.
O: Biodex, 20 min, resistance 3, 4 rest breaks, RPE scale 12/20, SOB scale 1/10 to increase endurance
and Le strength. Pt progressed FWW to a SPC requiring mod A. Pt tends to lean heavily on cane and
has a choppy gait pattern during gait training inside and outside the facility. Pt needed frequent rests
approximately every 50’ d/t fatigue. Pt had frequent LOB w/ SPC outside and needed to switch back
to FWW for safety and to help improve activity tolerance. Pt demonstrated a marked time pattern
during stair training in both directions, and seemed more unstable wanting to use both hand rails
instead of one at times requiring CGA.
A: Pt did progress to SPC but was very unstable requiring mod A assist instead of CGA. Pt did use ankle
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and hip strategies to stay upright during LOB. Pt did complete ther ex but still requires several rests.
Pt does display good safety awareness while performing ADL’s in room. Pt will benefit from skilled
therapy to improve LE strength, balance, and coordination.
P: Continue with POC and working on a more normalized gait pattern w/ SPC.
Problem(s) encountered by SPTA and outcome(s): None
Changes that need to be communicated to PT/nurse: None
Date: 5-29-14
Change of orders by doctor: None
Contraindications: None
Precautions: Sternal precautions, no lifting over 5#, HTN, fall risk
Patient’s medical status: Unchanged
S: Pt stated that he was feeling good and that today was going to be his last day at rehab. He decided
that he was ready to leave even though it was against medical advice.
O: Biodex, 20 min, resistance 4, 5 rests, RPE scale 12/20, SOB scale 2/10 to increase endurance and LE
strength. Berg Balance Test score of 41/56 which was a progression from previous score of 37/56. Pt
still shows substantial deficits in balance. Pt could not stand in tandum stance, on one foot, and had
LOB on the step test.
A: Pt did progress his Berg Balance Test score to 41/56, previous score 37/56. Pt is still at risk for a
potential fall. Pt can complete ther ex with more r3esistance but still requires many rests d/t fatigue in
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the LE’s. Pt has inadequate balance and endurance to complete ADL’s safely and independently.
P: Continue with Home Health to improve gait w/ assistive devices, stair training, balance, coordination,
and strength.
Problem(s) encountered by SPTA and outcome(s): None
Changes that need to be communicated to PT/nurse: None
Summary of Weekly Patient Progress Note(s)
Rationale for Daily Plan of Care (75 points):
*Note: Summarize daily treatment notes within each square.
Modalities Used:
Why Selected?
Outcome(s):
Progression (If no change, why?)
Therapeutic Exercises
(Medicare # 97110):
Why Selected (muscle exercise
directed to and why)?
Provided Outcome(s):
Explain Progression (If no change, why?)
1.Biodex
1. To warm up LE’s before tx
1.To increase endurance
1. No progression, pt did add resistance, but he
still required several rests to complete ther ex.
Neuromuscular Activities
(balance activities for
sitting, standing, etc.)
(Medicare # 97112):
Why Selected?
Provided Outcome(s):
Progression and Why?
None – not needed
1. Selected to see if pt has
1. Test results 41/56
compared to previous
1. Berg Test score did progress by 4
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1. Berg Balance Test
2. Dynamic standing
activities
Therapeutic Activities
(Bed mobility and
transfers that includes
assistive device if
needed, assistance
required, etc.)
(Medicare # 97530):
progressed
2. To improve balance
and posture
Why Selected?
1. To promote safety and
independence
score of 37/56.
2. Dynamic balance exercises
to help pt learn how to use
ankle/hip strategies.
Provided Outcome(s):
1. Pt did all transfers
independently w/ SBA
points, but the pt is still in the category
for a risk of a fall.
2. No progression w/ balance. Pt is still
very unstable with all balance activities.
The reason could be neuropathy in
feet, or decreased strength in both
LE’s.
Progression and Why?
1. Pt did show an improvement in
transfers from CGA to SBA.
1. Transfers
w/FWW
Gait (Include assistive
device(s) if used, level of
assistance needed,
distance, gait
abnormalities, etc.)
(Medicare # 97116):
1. SBA
2. FWW
3. SPC w/mod A
Why Selected?
1. Pt was able to
ambulate w/ FWW
requiring SBA
2. FWW selected because
it is the most stable AD
3. SPC was selected by pts
choice, but required
Provided Outcome(s):
1. Good pt on his way to
independence w/ FWW
2. Good choice to keep
sternal precautions until pt
becomes more stable
3. Pt was very unstable w/ the
SPC as he required more
assistance and his gait
Progression and Why?
1. Pt does very well w/ FWW and shows
descent safety awareness inside the
facility. He does not need CGA
anymore.
2. No progression w/ FWW. He has
always done well on even surfaces.
3. No progression w/ SPC. He has to work
on LE strength, balance, and
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mod assistance
Other: NONE
Why Selected?
pattern was more
compromised
Provided Outcome(s):
Goals Met (3 points):
Date Accomplished:
1. None, Pt decided to leave against medical advice
1. None
2.
2.
3.
3.
New Goals Initiated (3 points):
Date Initiated:
1. None
1. None
2.
2.
3.
3.
Interventions that were beyond scope of work or knowledge as a SPTA (2 points): None
coordination in order to progress to
cane.
Progression and Why?
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Student’s Name: Andrea Strickland
WEEK 3
Date:
SLCC Physical Therapist Assistant Program - Patient’s Initial Evaluation Homework Assignment
Initials of Patient (1 point): DB
Date seen by Physical Therapist (1 point): 6-1-14
Age (1 point): 60
Diagnosis (Including DOI, DOO or DOS) (3 points): Aftercare following joint replacement in left hip due to a fall, generalized muscle weakness,
difficulty in walking.
Medications (2 points): Enoxaparin sodium, Oxycodone HCL, Aspirin, Atorvastatin calcium, Fluticasone propionate, Lamotrigine, Oxybutynin,
Tylenol, Tubersol, Tramadol, Baclofen, Neurontin, Multivitamins, Potassium.
Medical Issues (past and present) (2 points): Fx to left trochanter of femur, CVA in 1999 resulting in left sided paresis, seizure disorder, subdural
hemotoma, neurogenic bladder.
Pertinent information
obtained from chart
review entered by
Physical Therapist
during “Patient’s Initial
Evaluation.”
(Medicare #: 97001)
Total: 40 points
1. Range of Motion Measurements: RLE ROM= WFL; LLE ROM=impaired (ORIF + paresis, tone)
2. Manual Muscle Test (MMT): RLE strength = 3-/5; LLE strength = 1/5
Trunk = 3-/5
3. Additional Data Collection: HR at rest = 89 beats/min; tone and posture symmetrical posture throughout; LLE tone,
spastic; gross motor coordination = impaired; sensation = impaired; vision = intact; cognition = safety awareness =
impaired
4. Bed Mobility (Move up and down in bed, supine<>EOB, etc): Total dependence w/ attempts to initiate
5. Transfers (Sit<>stand, bed<>w/c, w/c<> mat, etc): Total dependence w/ attempts to initiate; sit<> stand = total
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dependence w/ attempts to initiate
6. Sitting: Static = unable, total dependence Dynamic = unable, total dependence
7. Standing: Static = unable, total dependence Dynamic = unable, total dependence
8. Ambulation/Stairs: Level surfaces = Total dependence w/o attempts to initiate; Distance level surfaces = N/A; Assistive
Device = DNT; Uneven Surfaces = DNT
9. Special Tests: None specified in chart
Patient’s Goals: “ I want to be able to walk to the bathroom”.
Short Term Goals (5 points):
1) Pt will increase trunk strength to 5/5 in order to increase core strength for functional activities and facilitate
upright posture (target 6-28-14)
2) Pt will increase RLE strength to 4+/5 to facilitate pts ability to perform transfers w/ SBA w/ use of AD while
maintaining good balance and w/ implementation of compensatory strategies in order to facilitate increased
independence w/ functional mobility throughout facility (target 6-28-14)
3) Pt will increase static sitting balance to g-/F+ spontaneously righting self when needed in order to participate in
EOB activities and facilitate safety coming to stance (target 6-28-14)
4) Pt will increase static sitting balance to fair-spontanously righting self when needed and w/ability to right self to
achieve balance w/ implementation of compensatory strategies in order to prepare for gait activities and decrease
need for A during mobility/ ADL’s (target 6-28-14)
Long Term Goals (5 points):
1) Pt will safely perform functional transfers w/ modified independence w/ minimal pain and w/ improved ROM and
coordination in order to safely return to private residence w/ reduced risk for falls.
2) Pt will safely ambulate 30 feet using SPC on level surfaces w/ modified independence w/ ability to right self to
achieve balance and w/ minimal pain in order to allow pt to get to bathroom w/ decreased assistance (target 6-2814)
Physical Therapist’s Plan of Care/Planned Interventions (10 points):
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1) Therapeutic exercises (97110)
2) Neuromuscular reeducation (971120
3) Gait training therapy (97116)
4) Therapeutic activities (97530)
Frequency: 5 times per week
Duration: 4 weeks
Intensity: Daily
Student Analysis of
Physical Therapist’s
Information
Contraindications (i.e. movement precautions, aspiration history and head must be 35 degrees or higher in supine
position, etc) (3 points): None Specified in chart
Safety Considerations for Patient (i.e. cardiac history, aspiration with clear fluids, pacemaker, atrial fibrillation, dementia,
COPD, on supplemental O2, etc.) (5 points): fall risk, seizure disorder, WB as tolerated, complicated medical hx
Additional Information Needed and Rationale (MMT, ROM measurements, etc.) (4 points): pain at rest 4/10 constant in
left hip; pain with movement 10/10 occasional in left hip
Functional Problem List (10 points):
1. Pt has limited core strength.
2. Pt has no strength in LLE due to CVA in 1999, and had hip surgery on this side.
3. Pt is at high risk for falls.
4. Pt is terrified of putting weight on her left leg and when she gets nervous her tone sets in then she can’t move for transfers.
5. Pt is totally dependent with all transfers, bed mobility, and ADL’s.
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Questions for Physical Therapist Related to Initial Evaluation (5 points):
1. Why was there no special tests performed on pt?
2. Why was there no goniometric measurements taken?
Equipment Considerations (3 points): Parallel bars, Omnicycle, Biodex, ankle weights, sliding board, leg lifter
SLCC Physical Therapist Assistant Program – Weekly Patient Progress Note Assignment
Daily Treatment Notes for Week (25 points/daily note, total of daily notes/number of daily notes= average out of 25 points):____________
Date: 6-2-14
Change of orders by doctor: None
Contraindications: None
Precautions: Fall risk, seizure disorder
Patient’s medical status: Unchanged
S: Pt stated that she had a lot of pain in her left hip at the surgery incision and asked us to move her very slow and steady.
O:Pt required mod x2 for all bed mobility activities, transfers, and to get to the toilet. Pt required a lot of time for each transfer d/t pain in the
left hip. Pt is unable to move left leg independently because of CVA. Pt participated in bed mobility exercises to strengthen the right foot; 3 min
of ankle pumps, heel slides and leg lifts, needing rests between each exercise. MHP during the ex to decrease pain in left quad, 9 towel layers, 15
min, mild, blanchable erythema noted after tx. Pt required CGA during seated balance exercises d/t weak core and pore posture. Pt required
mod x 2 to pull up to standing w/ UE support, pt was able to stand for 6.5 min until she needed a seated rest.
A: Pt requires a lot of time for transfers and bed mobility d/t left paresis and hip syrgery. Pt is very afraid of falling and needs constant
21
reassurance. Pt also needs multiple cues to stay on task as she wants to do things her way, but are inefficient and unsafe.
P: Continue w/ POC, and focus on putting weight on left leg to help w/ transfers.
Problem(s) encountered by SPTA and outcome(s): Only problem is the pt is very heavy and terrified of moving. I feel bad, and wish there was
more I can do, but she has to move and trust us that we wont drop her. The outcome was good, she was proud of herself that she stood for 6
min.
Changes that need to be communicated to PT/nurse: She definitely needs her pain medication before therapy.
Date: 6-3-14
Change of orders by doctor: None
Contraindications: None
Precautions: Fall risk, seizures
Patient’s medical status: unchanged
S: Pt stated that she was ready for therapy and wanted to stand longer then previous day. Her sister was w/ her for support.
O: Omnicycle to increase activity tolerance and LE strength. 20 min, resistance 2, 88% activity level, rests only to help reposition left foot d/t
clonus attacks. MHP to left quad to decrease pain, 15 min, 9 towel layers, mild, blanchable erythema noted after tx. Pt participated in a FIST
test w/ a score of 46/56. Pt required mod 2 assist during all transfers from w/c to mat table, and max assist to pull up to standing w/ UE support.
22
Pt requires many verbal and manual cues to position left foot to stand or transfer and also to use right leg and arm more to help w/ motion. Pt
was able to stand for 10 min before needing a seated rest.
A: Pt did progress standing activities to 10 min from 6.5 in the previous tx. Pt still requires a lot of assistance to move or complete ADL’s. Pt did
a FIST test w/ a score of 46/56, the deficits from the test was lateral scooting and reaching d/t pain in left hip. Pt is still terrified to move, but it
seemed she was more confident today. I think it is because she had the support of her sister.
P: continue w/ POC
Problem(s) encountered by SPTA and outcome(s): None
Changes that need to be communicated to PT/nurse: None
Date: 6 4-14
Change of orders by doctor: None
Contraindications: None
Precautions: Fall risk, seizures
Patient’s medical status: Unchanged
S: Pt stated that she was doing well with little pain and ready for therapy.
O: Biodex to increase activity tolerance and LE strength. 20 min, 0 resistance, SOB scale 0/10, pain scale 7/10, RPE scale 6/20. Pt required max x
2 assist to get on the bike which took about 20 min total to transfer. Pt began to get very afraid of falling and needed constant verbal and
manual cues to position feet and use right leg and arm to help. MHP to left quad to decrease pain, 15 min, 9 towel layers, mild, blanchable
erythema noted after tx. Pt required max x 2 to transfer off bike and into w/c, this transfer took about 30 min. Pt began to really feel unsteady
and anxious. When the pt started to get uptight her tone would kick in and make her motionless. Pt required constant reassurance, verbal, and
manual facilitation to pivot feet and put some weight on left leg to help right foot turn. Pt was struggling so we put a turn table under her feet
23
to help her turn her feet and sit in w/c.
A: Pt still needs assistance for all activities and ADL’s d/t inadequate strength, coordination, and balance to complete tasks independently. Most
of the tx time today was spent on transferring.
P: Continue w/ POC.
Problem(s) encountered by SPTA and outcome(s): Pts fear of falling to where her tone kicks in and makes her motionless. Pt really had a hard
therapy session today and it could have gone so much smoother. The outcome was good because she didn’t fall even though I thought she
might a couple times. She literally got paralyzed w/ fear.
Changes that need to be communicated to PT/nurse: Maybe anti anxiety meds??
Date: 6-5-14
Change of orders by doctor: None
Contraindications: None
Precautions: Fall risk
Patient’s medical status: Unchanged
S: Pt stated that she was very tired and not feeling well.
O: Pt required mod x2 assist to come up to standing w/ UE support. Pt was able to weight shift onto the left foot which pt stated that it wasn’t
painful. Pt progressed to lift right hand off support while putting weight on left foot and would lift right toes up. Pt did this for about 10 min.
Omnicycle, 20 min, resistance 3, RPE scale 6/20, pain scale 8/10, SOB scale 0/10, rests only to position left foot d/t spasticity. MHP to left quad
to decrease pain, 15 min, 9 towel layers, mild, blanchable erythema noted after tx. Pt began to complain about nausea during ther ex. After
ther ex pt wanted to go back to her room. Pt still had 30 min of tx time and was offered alternative activities to complete for therapy but
24
insisted on leaving.
A: Pt did progress standing exercise by adding weight shifts to bear more weight on left foot, pt was able to lift right hand and toes to also. Pt
began to feel nauseous after ther ex and insisted on leaving. Pt has poor activity tolerance and strength to complete tasks and ADL’s
independently and safely. Pt still requires assistance for all activities and would benefit from continuing skilled therapy to improve these
deficits.
P: Continue w/ POC
Problem(s) encountered by SPTA and outcome(s): None
Changes that need to be communicated to PT/nurse: None
Date: 6-6-14
Change of orders by doctor: None
Contraindications: None
Precautions: Fall risk, seizures
Patient’s medical status: Unchanged
S: Pt stated that she was feeling better than yesterday and said she was a little upset at Sam and I for not putting her back into bed when she left
therapy yesterday.
O: Pt required mod assist to get sat up on edge of bed to begin transfering to w/c. Pt required CGA while sitting on edge of bed d/t weak core
muscles and lack of use of left arm. Pt was able to scoot onto w/c but needed mod assist to get situated in seat. Pt participated in seated
transferring activities from mat table to w/c, scooting the right side of body towards destination. Pt does require assist to get in position d/t pain
in the left leg. Omnicycle, 20 min, resistance 3, rests to get left foot positioned d/t spasticity, SOB scale 0/10, RPE 5/20, pain scale 7/10. MHP to
25
left quad, 15 min, 9 towel layers, mild, blanchable erythema noted after tx.
A: Pt did well on scooting activities but did need assistance to get fully positioned at end of movement. Pt is beginning to move a little faster,
but still requires lots of time to complete any transferring activity. Pt still gets very nervous w/ fast movements and will insist you to slow way
down so her left leg can catch up to her. Pt still requires assistance with all activities and would benefit from continuing skilled therapy to
improve activity tolerance, strength, and transfers.
P: Continue W/ POC.
Problem(s) encountered by SPTA and outcome(s): None
Changes that need to be communicated to PT/nurse: None
Summary of Weekly Patient Progress Note(s)
Rationale for Daily Plan of Care (75 points):
*Note: Summarize daily treatment notes within each square.
Modalities Used:
Why Selected?
Outcome(s):
Progression (If no change, why?)
Hot Pack
To decrease pain in the left
quad
Pt stated that it helped after every
tx
No progression, pts surgery site is on the left
hip, so it still is painful most of the time.
Therapeutic Exercises
(Medicare # 97110):
Why Selected (muscle exercise
directed to and why)?
Provided Outcome(s):
Explain Progression (If no change, why?)
1. Omnicycle
1. To warm up muscles and
keep left foot strapped in
1. Pt was able to do full minutes
but had to stop frequently to keep
left foot positioned d/t spasticity
1. No progression, pt is still on same resistance
and time. Pt has to stop often to reposition
2.Biodex
2. Pt was able to complete
26
3. Bed exercises
place
exercise, but it took about 50 min
to transfer to and from bike , so its
not a very time efficient activity
2. To warm up muscles and
use arms at same time
3. Good outcomes, pt stated that
they are easy for her to do while in
bed
3. easy exercises pt can do
while in bed
Neuromuscular Activities
(balance activities for
sitting, standing, etc.)
(Medicare # 97112):
Standing activities,
sitting activities,
transfers, and bed
mobility activities
2. No progression, we only tried this machine
once because its too complicated to use at this
time d/t the time it takes to get her on/off it.
3. No progression, we only practiced these
exercises once while treating this pt.
Why Selected?
Provided Outcome(s):
Progression and Why?
None
None
Havn’t done these activities yet because it’s
such a chore to get pt just to transfer. We are
working on transfers and standing balance
first which my CI said is considered
therapeutic activities instead of neuro.
Why Selected?
Provided Outcome(s):
Progression and Why?
To get pt accustomed to
putting weight on left foot to
help us w/ transfers.
Standing balance is going good
There is progression w/ standing. Pt is able to
start putting more weight on left leg
Sitting activities to help her
strengthen core muscles
Transfers and bed mobility need a
lot of work also
None
Therapeutic Activities
(Bed mobility and
transfers that includes
assistive device if
needed, assistance
required, etc.)
(Medicare # 97530):
foot
Transfers and bed mobility to
help her become independent
Sitting balance needs a lot of work
Sitting has not progressed because pt always
has help coming to sit and never attempts to
do it alone
Transfers and bed mobility are progressing in
the time it takes because that’s what we
practice the most, but it still requires at least
27
half the tx time.
Gait (Include assistive
device(s) if used, level of
assistance needed,
distance, gait
abnormalities, etc.)
(Medicare # 97116):
Why Selected?
Provided Outcome(s):
Progression and Why?
None
None
Have not even attempted gait training, Pt cant
even stand w/o support and cannot use
walker yet d/t pain in hip and atrophy of left
leg. This is the pts main goal and we are
working on strengthening those legs and
standing first.
Why Selected? None
Provided Outcome(s): None
Progression and Why? None
None
Other: None
Goals Met (3 points):
Date Accomplished:
1. none
1. none
2.
2.
3.
3.
New Goals Initiated (3 points):
Date Initiated:
1. none
1. none
2.
2.
28
3.
3.
Interventions that were beyond scope of work or knowledge as a SPTA (2 points): None
WEEK 4
SLCC Physical Therapist Assistant Program – Weekly Patient Progress Note Assignment
Daily Treatment Notes for Week (25 points/daily note, total of daily notes/number of daily notes= average out of 25 points):____________
Date: 6 -9 -14
Change of orders by doctor: None
Contraindications: None
Precautions: Fall risk, seizures
Patient’s medical status: Unchanged
S: Pt stated that she had a good weekend and that she was ready for therapy. Pain scale 8/10.
O: Omnicycle to improve activity tolerance and LE strength. 20 min, 89% activity level, SOB 0/10, RPE 13/20. MHP on left hip and knee to
decrease pain, 15 min, 9 towel layers, mild, blanchable erythema noted after tx. Dynamic standing activities using mat table and berry rehab
board to facilitate weight shifting to prepare for gait. Pt requires many verbal, manual, and tactile cues to stay on task and shift weight onto left
foot. Pt used a mirror to see that she leans too much to the right to keep weight off left side. Pt was able to tap right toes, but had a hard time
29
lifting right heel. Pt was able to scoot herself into w/c w/ SBA. Pt required CGA while sitting on edge of bed 40 % of the time during bed mobility
activities.
A: Pt progressed the time it takes to transfer and was able to scoot herself into w/c w/ SBA. Pt still has a hard time shifting weight onto left foot
to help make transfers easier and faster. Pt still complains of severe pain in left hip but overall is trying her best. Pt has poor activity tolerance,
strength, and standing balance to participate in ADL’s safely and independently. Pt will benefit from continuing skilled therapy to improve these
areas.
P: Continue to work on independent transfers and standing tolerance.
Problem(s) encountered by SPTA and outcome(s): None
Changes that need to be communicated to PT/nurse: None
Date: 6-10-14
Change of orders by doctor: None
Contraindications: None
Precautions: fall risk, seizures
Patient’s medical status: Unchanged
S: Pt stated that she was feeling well, pain scale was 7/10.
O: Biodex to improve activity tolerance. 10 min, no resistance, no rests. MHP to left hip and groin area to decrease pain. 7 towel layers, 10 min,
mild, blanchable erythema noted after tx. Pt did CKC exercises w/ pillow case under left foot but cannot on the right d/t inability to put weight
on left foot. Pt participated in standing exercises w/ UE support. Pt was able to stand and cross mid line to grab objects in attempt to weight
30
shift on left foot. Pt still demonstrated difficulty in weight shifting even when objects were moved further away. Pt requires multiple cues to
stay on task and upright during standing activities. Pt required SBA for 50 % of transfers and min assist for the other 50%.
A: Pt is improving on transfers only requiring SBA while she scoots herself into w/c or mat table. Pt is able to pull herself up to stand w/ many
attempts. Pt is still having pain in left hip that is affecting her ability to weight shift on left leg. Pt needs to work i=on this task in order to
ambulate. Pt progressed to Biodex bike instead of Omnicycle d/t her ability to transfer more efficiently.
P: Continue to weight shift and increase standing tolerance.
Problem(s) encountered by SPTA and outcome(s): None
Changes that need to be communicated to PT/nurse: None
Date: 6-11-14
Change of orders by doctor: None
Contraindications: None
Precautions: Fall risk, seizures
Patient’s medical status: None
S: Pt stated that she was fine and ready for therapy. Pain scale 7/10.
O: Pt required SBA for 80% of transfers and min assist 20 %. Pt is able to scoot herself into w/c or mat table w/ SBA. Pt is able to pull herself to
standing using UE support and requiring assistance 20% of the time. Biodex to improve activity tolerance and LE strength. 20 min, 0 resistance,
no rests, SOB scale 0/10, RPE scale 7/20. MHP to left knee and hip to decrease pain, 9 towel layers, 15 min, mild, blanchable erythema noted
after tx. Pt was put on unweighted system to improve weight shifting tolerance to prepare for gait training. Pt was able to shift to left side
leaning into the left bar on mat table. Pt practiced moving right foot back and forth using targets on the floor. Pt completed 6 steps then
31
required a seated rest. Pt did complain of left hip pain throughout activity.
A: Pt progressed to Biodex bike because she is able to transfer more efficiently. Pt was able to put some body weight on left foot because she
was hooked up to the unweighted system. Pt still needs to work on putting all body weight on left foot and standing posture. Pt has poor
activity tolerance and balance. Pt will benefit from continuing skilled therapy to improve these areas.
P: Continue to progress standing activities, transfers, and LE strength to prepare for ambulation.
Problem(s) encountered by SPTA and outcome(s): None
Changes that need to be communicated to PT/nurse: None
Date: 6-12-14
Change of orders by doctor: None
Contraindications: None
Precautions: Fall risk, seizures
Patient’s medical status: Unchanged
S: Pt stated that she was tired and nervous for what we had in store for her today. She stated that she does not like the unweighted system.
O: Pt is able to transfer needing SBA while scooting into w/c or mat table. Pt requires mod assist to come to stand. Pt stresses herself out during
transfers at times which makes her very anxious to complete transfer. Pt needs lots of encouragement and support when this happens. Pt works
best when you give short precise cues as of what to do next and where to place feet during stand pivot transfers. Pt did not want to use
unwieghted system so she participated in dynamic standing activities using UE support on both sides. Pt was unable to weight shift onto left
foot d/t pain in left hip, until we provided targets for her to put feet to. Pt was able to slowly scoot right foot to targets. Pt required several
verbal, tactile, and manual cues to move feet during stranding activity and to stay on task. Biodex to improve activity tolerance and LE strength.
20 min, 0 resistance, no rests, SOB scale 0/10, RPE scale 6/20. MHP on left knee and hip area to decrease pain, 15 min, 9 towel layers, mild,
32
blanchable erythema noted after tx.
A: Pt still cannot put weight onto left leg to improve standing tolerance. Pt is still doing good on transfers and pulling herself to stand. Pt is still
complaining of pain in left hip and is always asking why she is hurting so bad. Pt has poor standing and activity tolerance and would benefit from
continuing skilled therapy to improve these deficits.
P: Continue to use unweighted system to facilitate weight shifting to prepare for gait training.
Problem(s) encountered by SPTA and outcome(s): None
Changes that need to be communicated to PT/nurse: None
Date: 6-13-14
Change of orders by doctor: None
Contraindications: None
Precautions: Fall risk, seizures
Patient’s medical status: Unchanged
S: Pt stated that she was tired but willing to do whatever we asked today. Pain scale 5/10.
O: Pt required SBA for all seated transfers and mod assist for stand pivot transfers on/off toilet and on/off mat table. When doing stand pivot
transfers, pt needs multiple verbal and tactile cues as of where to go and what to do next. Pt was put on unweighted system to facilitate
standing tolerance and weight shifts. Pt was able to roll a ball under right foot while standing on left. Pt still leaned into mat table but
completed task. Pt did this activity using a platform walker to support the right arm. Pt was able to take very small and slow steps w/ both feet.
Biodex to improve activity tolerance and LE strength. 20 min, 0 resistance, no rests, SOB 0/10, RPE 6/20. MHP to left knee and hip to decrease
pain and stiffness, 15 min, 9 towel layers, mild, blanchable erythema noted after tx.
33
A: Pt progressed standing activity using unweighted system while rolling a ball under her right foot to put weight on left. Pt is still doing good on
transfers and pulling herself to stand. Pt complains of pain in hip but is trying to prepare herself for ambulation. Pt has poor activity tolerance
and strength to participate in ADL’s safely and independently.
P: Continue using unweighted system to facilitate weight shifting to begin gait training.
Problem(s) encountered by SPTA and outcome(s): None
Changes that need to be communicated to PT/nurse: None
Summary of Weekly Patient Progress Note(s)
Rationale for Daily Plan of Care (75 points):
*Note: Summarize daily treatment notes within each square.
Modalities Used:
Why Selected?
Outcome(s):
Progression (If no change, why?)
Hot packs
To warm up tissues and
decrease pain
Pt stated that she always feels
better after hot pack
No progression w/ hot pack because its just to
warm up and take pain away.
Therapeutic Exercises
(Medicare # 97110):
Why Selected (muscle exercise
directed to and why)?
Provided Outcome(s):
Explain Progression (If no change, why?)
1.Omnicycle
1.to warm up
1. Pt completed exercises well
2.to warm up
2. Pt progressed to this bike and
did well
1. No progression, pt has a hard time keeping
foot in the pedal of this machine
3.to strengthen LE’s for gait
3. Pt was able to do left foot but
not right one d/t pain in left
hip/knee
2. Biodex
3.CKC LE exercises
2. Pt progressed to this machine because of
her ability to transfer on/off it w/ confidence.
34
3. Pt did not progress because she will not put
weight on left foot d/t pain.
training
Neuromuscular Activities
(balance activities for
sitting, standing, etc.)
(Medicare # 97112):
1. Unweighted
System
2. Dynamic
standing
activities
Why Selected?
1. To give pt comfort that
she cant fall and to
take some weight off
her
2. To facilitate standing
tolerance and prepare
for gait training.
Therapeutic Activities
(Bed mobility and
transfers that includes
assistive device if
needed, assistance
required, etc.)
(Medicare # 97530):
Provided Outcome(s):
1. Pt didn’t like it but did
what we asked
2. Pt was able to shift some
weight off right foot for
seconds at a time, and
move foot towards targets
on the floor.
Progression and Why?
1. Pt does progress standing tolerance
w/ unweighted system because it
helps take some body weight off her
feet.
2. Pt progresses when she has targets to
step too w/ feet but requires lots of
cues.
Why Selected?
Provided Outcome(s):
Progression and Why?
Why Selected?
Provided Outcome(s):
Progression and Why?
Pt is scooting herself
in/out of w/c w/o using
any devices. Pt also does
not use devices with
stand pivot transfers.
She only uses w/c.
Gait (Include assistive
device(s) if used, level of
assistance needed,
distance, gait
abnormalities, etc.)
35
(Medicare # 97116):
Not yet, hopefully next
week. I want to see her
walk before I leave 
Other: None
Why Selected?
Provided Outcome(s):
Goals Met (3 points):
Date Accomplished:
1. None
1. None
2.
2.
3.
3.
New Goals Initiated (3 points):
Date Initiated:
1. None
1. None
2.
2.
3.
3.
Interventions that were beyond scope of work or knowledge as a SPTA (2 points): None
Progression and Why?
36
Week 5
SLCC Physical Therapist Assistant Program – Weekly Patient Progress Note Assignment
Daily Treatment Notes for Week (25 points/daily note, total of daily notes/number of daily notes= average out of 25 points):____________
Date: 6-16-14
Change of orders by doctor: None
Contraindications: None
Precautions: Fall risk, siezures
Patient’s medical status: Unchanged
S: Pt stated that she was doing good.
O: Pt required CGA for all gait training activities and transfers. Biodex, 10 min to warm up at level 1, then adj to 15 after 5 min to improve LE
strength and activity tolerance. Weight shifting exercises to increase weight tolerance on left foot. Pt was afraid to step w/ right foot and that
left knee would buckle. Pt was able to step w right foot if manual pressure is applied to left knee.
A: Pt presented improvements in weight shifting and able to move right leg forward during gait training. Pt will benefit from continuing skilled
therapy to improve activity tolerance, strength, and gait.
P: Continue w/ plan of care.
Problem(s) encountered by SPTA and outcome(s): None
37
Changes that need to be communicated to PT/nurse: Talk to PT about knee brace for gait
Date: 6-17-14
Change of orders by doctor: None
Contraindications: None
Precautions: Fall risk, seizures
Patient’s medical status: unchanged
S: Pt stated that she was tired.
O: Biodex to improve activity tolerance and LE strength. 20 min, 0 resistance, SOB 4/10, RPE 4/20, Pain scale 4/10MHP to left knee during ther
ex to decrease pain, 15 min, 9 towel layers, mild, blanchable erythema noted after tx. Pt practiced gait training using platform walker and
unweighted system. Pt went 4’ and was able to go backwards at a faster speed. Pt required SBA to CBA for all transfers and coming to stand.
A: Pt isprogressing the time it takes to transfer and weight shifting but is still anxious about shifting 100 % weight on left leg. Pt still presents
poor standing balance and activity tolerance. Pt will benefit from continuing skilled therapy to improve these deficits.
P: Continue gait training w/ unweighted system.
Problem(s) encountered by SPTA and outcome(s): None
38
Changes that need to be communicated to PT/nurse: None
Date: 6-18-14
Pt was seen by therapist on this day.
Change of orders by doctor:
Contraindications:
Precautions:
Patient’s medical status:
S:
O:
A:
P:
Problem(s) encountered by SPTA and outcome(s):
Changes that need to be communicated to PT/nurse:
Date: 6-19-14
Change of orders by doctor: None
Contraindications: None
39
Precautions: Fall risk, seizures
Patient’s medical status: Unchanged
S: Pt stated that she was tired.
O: Biodex to improve LE strength and endurance. 20 min, 0 resistance, RPE 12/20, SOB 6/10, pain 4/10 pain in left hip and left knee. MHP to left
knee for 15 min during ther ex to decrease pain. Pt reported that pack got too hot so another layer of towels was added. Mild, blanchable
erythema to treated area after hot pack. Pt required assist of unweighted system and platform walker. Pt was able to go 6’ which took 8 min w/
max VCs, pt took seated rest then attempting to go a longer distance, pt had trouble moving R leg d/t inability to weight shift on left leg. Pt
completed 5 more feet but it took much longer needing more Vs and manual assistance.
A: Pt progressed the distance that it took to ambulate then previous tx’s. Pt is still anxious of weight shifting. Pt will benefit from continuing
skilled therapy to improve these deficits.
P: Continue w/ POC.
Problem(s) encountered by SPTA and outcome(s): None
Changes that need to be communicated to PT/nurse: None
Date: 6-20 -14
Change of orders by doctor: None
Contraindications: None
Precautions: Fall risk, seizures
Patient’s medical status: Unchanged
40
S: Pt stated that she was well and that she was going to walk for me my last day here.
O: Gait training to normalize gait pattern, training in increased BOS, adjustment of COM over BOS, training in correct hand/ foot placement
during gait , weight shift during mobility, facilitation of symmetrical stance. Pt required SBA during gait activities w/ platform walker and
unweighted system. Pt was able to go 6’ then needed a seated rest. Pt attempted more gait training but had trouble advancing LE’s and
required manual and verbal cues but was still unable to complete task. Biodex to improve endurance, 20 min, 0 resistance, SOB 0/10, pain 0/10,
RPE 4/20. Pt had IFC during tx to decrease pain. IFC, 4 electrodes, left knee, channel one 28mA, channel 2 41 mA, 15 min. Pt required SBA to
CGA for all transfers and gait training.
A: Pt is still unable to fully weight shift to take normal strides. Pt is progressing with unweighted system but frequently gets very anxious and
wants to stop. Pt has poor activity tolerance and strength to complete ADL’s independently and safely. Pt will benefit from continuing skilled
therapy to improve these areas.
P: Continue w/ POC
Problem(s) encountered by SPTA and outcome(s): None
Changes that need to be communicated to PT/nurse: None
Summary of Weekly Patient Progress Note(s)
Rationale for Daily Plan of Care (75 points):
*Note: Summarize daily treatment notes within each square.
Modalities Used:
1. Hot packs
2. IFC
Why Selected?
Outcome(s):
Progression (If no change, why?)
To decerase pain in left
knee/hip.
Pt stated that they temporarily
ease the pain.
No progression.
41
Therapeutic Exercises
(Medicare # 97110):
Why Selected (muscle exercise
directed to and why)?
Provided Outcome(s):
Explain Progression (If no change, why?)
1.Biodex
1. to warm up
1. pt stated that it does help warm
up
2.
2.
1. No progession, pt needs to tolerate a faster
pace and increase the resistance on the bike
3.
3.
2.
3.
2.
3.
Neuromuscular Activities
(balance activities for
sitting, standing, etc.)
(Medicare # 97112):
Why Selected?
Provided Outcome(s):
Progression and Why?
Why Selected?
Provided Outcome(s):
Progression and Why?
None
Therapeutic Activities
(Bed mobility and
transfers that includes
assistive device if
needed, assistance
required, etc.)
(Medicare # 97530):
1. Platform walker
1. To support LUE and elp
to support weight for
weight shifting
tolerance.
1. Pt has a hard time because
she is used to letting er
LUE just hang down, she
says that it balances her.
1. The platform walker is a progression
because it puts er LUE in the right
position to help distribute body
weight so pt can ambulate.
2. wheelchair
2. w/c for transportation
2. Good
2. Only progression using the w/c is pts
ability to slide in/out of it at a way
faster speed,a nd w/SBA.
Gait (Include assistive
device(s) if used, level of
assistance needed,
distance, gait
abnormalities, etc.)
Why Selected?
1. To help take weight off
Provided Outcome(s):
1. Pt was able to ambulate
w/ the unweighted
Progression and Why?
1. The unweighted system is a
progression because it helps take
42
(Medicare # 97116):
pt so she can ambulate
1. Unweighted
system
system. Pt still has a hard
time shifting weight.
some weight off so pt is somewhat
willing to take small steps.
2. SBA to CGA
3. Up to 6’
4. Very small step
lengths and
inability to
weight shift
Other: None
Why Selected?
Provided Outcome(s):
Goals Met (3 points):
Date Accomplished:
1. None
1. None
2.
2.
3.
3.
New Goals Initiated (3 points):
Date Initiated:
1. None
1. None
2.
2.
3.
3.
Progression and Why?
43
Interventions that were beyond scope of work or knowledge as a SPTA (2 points): None