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Progress Note Patient has participated and demonstrated improvement with skilled physical therapy. Patient has an improved balance based on the Berg Balance Scale with a score of ­_ indicating a reduction in risk for falls. Patient ambulated _ft in 6 minutes on the 6 MWT which is closer to patient’s age-related normative value. Patient has demonstrated pain reduction with a pVAS score of _.  Patient able to complete _ sit to stands during the 30 sec Chair Stand Test indicating an increase in LE functional strength and improvements towards patient’s age-related normative value. Patient has improved in safety awareness indicating a reduction in risk for falls. Physical therapy has facilitated static and dynamic balance, pain reduction techniques, LE and core strengthening, activity tolerance training and progression, and safety awareness for improvements in patient’s ability to get around apartment and facility safely and with improved endurance, improve transfer ability, and reduce risk

  Evaluation Treatment Diagnosis Muscle Weakness (M62.81), Unsteadiness on Feet (R26.81), Repeated Falls (R29.6) Reason For Referral [Mr./Ms.] is a _ y.o who has been referred to PT by [ALF staff, PCP, etc.] with reports of pt having _________ affecting [ambulation, safety, mobility, transfers, etc.] Staff reports pt has had multiple falls since their last discharge from PT. Example: Mr. L has been referred for PT by ALF staff with reports of having increased knee pain affecting ambulation and safety. Staff reports pt has had multiple falls since his last discharge from PT. Caregivers report that pt has been using facility provided w/c for mobility in addition to walker for ambulation. Caregivers also report that pt has not been participating as much and is in bed more often. Pt has had a recent stint of PT from 12/22/2020 – 4/9/2021. Therapy Necessity During assessment, patient scored _ on the Elderly Mobility Scale indicating reduced safety with mobility and independenc

FGA CVA: MDC: 4.2 points (5 points clinically) Vestibular disorders: MDC: 6 points Community-dwelling older adults: MCID: 4 points Cut-off scores: </= 22/30 is a predictor of falls as well as a fall risk. PD: MDC: 4 points Cut-off scores: </= 18/30 identifies a fall risk. BBS Older adults: MDC: with initial scores of 0-24=4.6, 25-34=6.3, 35-44=4.9, 45-56=3.3 Cut-off scores: <45 indicates may be at greater risk of falls Cut-off scores: <40 associated with almost 100% fall risk CVA: MDC: anywhere from 2.5 points to 6.9 points Cut-off scores: 45 out of 56 Vestibular disorders: Cut-off scores: score of 45/56 indicates functional ability PD: MDC: 5 points Berg sheet: Score of 41-56: low fall risk, 21-40: medium fall risk, 0-20: high fall risk A change of 8 points is required for MCID. DGI Older adults: MCID: 2 Cut-off scores:         For community-dwelling elderly, < 19 = increased fall risk CVA: MDC: 4 PD: MDC: 3 points Cut-off scores: < 19 = increased risk for fall

Evaluation Treatment Diagnosis Muscle Weakness (M62.81), Unsteadiness on Feet (R26.81), Repeated Falls (R29.6) Reason For Referral [Mr./Ms.] is a _ y.o who has been referred to PT by [ALF staff, PCP, etc.] with reports of pt having _________ affecting [ambulation, safety, mobility, transfers, etc.] Staff reports pt has had multiple falls since their last discharge from PT. Example: Mr. L has been referred for PT by ALF staff with reports of having increased knee pain affecting ambulation and safety. Staff reports pt has had multiple falls since his last discharge from PT. Caregivers report that pt has been using facility provided w/c for mobility in addition to walker for ambulation. Caregivers also report that pt has not been participating as much and is in bed more often. Pt has had a recent stint of PT from 12/22/2020 – 4/9/2021. Therapy Necessity Pt presents with: [reduced LE strength, functional mobility, reduction in pain, gait pattern, transfers, activity tolerance, balance, rig