ALF / ILF Cheat Sheet (Casamba) - Shortened Version
Progress Note
Patient has been educated on safety awareness with assistive device during gait and maneuvering around patient’s apartment, improved gait mechanics for improved stability with gait, as well as importance of physical therapy and continuing to ambulate regularly. Patient has improved in their carryover with education and demonstrating increased safety awareness and gait mechanics.
Rem: Patient has demonstrated improvements towards short- and long-term goals. Patient continues to require skilled physical therapy to improve static and dynamic balance, LE and core strengthening, activity tolerance training, 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 for falls.
Imp: Patient has improved in their balance based on balance assessment, however, remains a fall risk requiring assistance from staff for safety with various functional tasks such as ambulation, transfers, toileting, etc. Patient has demonstrated improvements in activity tolerance based on 6MWT, however occasionally requires assistance when maneuvering around facility.
Upd: Based on patient’s personal goals, patient’s performance on tests and measures, and communication from other therapists, interventions continuing to address static and dynamic balance, pain reduction techniques, LE and core strengthening, activity tolerance training, and safety awareness are appropriate for this patient.
Patient's willingness to participate in skilled physical therapy to return to PLOF and improvements demonstrated since initial evaluation.
Intervention Assessments:
Therapeutic Exercise:
Assessed patient’s ambulation tolerance and aerobic capacity with the 6MWT. Patient ambulated with _ and required CGA/SBA. Assessment of fatigue based on the Borg RPE scale.
Assessed patient’s functional LE strength with the 30 second CST. Patient able to complete _x sit to stands in 30 seconds with / without BUE for push off from armrest. Facilitated additional sit to stands, _x with / without BUE for push off from armrest, for improvements in LE strength required for functional transfers. Patient tolerated assessment and interventions appropriately.
Therapeutic Activity:
Assessed patient’s bed mobility. Patient required SBA for sitting on edge<>supine. Patient required verbal cues for correct technique. Facilitated additional bed mobility training for improvements in overall strength and technique for carryover.
Assessed patient's transfer ability going from WC<>seated edge of bed. Patient required _ and verbal cues for correct technique.
Assessed patient’s stability with gait based on Timed Up and Go utilizing FWW and requiring CGA.
Neuro re-education:
Assessed patient’s static balance and risk for falls with the Berg Balance Scale. Additional balance exercises performed based on the Berg Balance Scale requiring CGA<>SBA for improvements in balance reaction and ankle and hip strategies for reduction in risk for falls. Patient tolerated assessment and interventions appropriately.
Assessed patient’s dynamic balance and risk for falls with the Dynamic Gait Index. Additional balance exercises performed based on the DGI requiring CGA<>SBA with exercises including incorporation of vestibular input, changes in gait speed, single leg stance with stepping over obstacles, turns, and ambulation around obstacles, for reduction in risk for falls and stability with gait. Patient tolerated assessment and interventions appropriately.
Assessed patient’s seated balance with the Function in Sitting Test. Patient required supervision<>CGA depending on test item. Facilitated additional balance exercises from the FIST for improvements in balance reaction and core strength required for reduction in risk for falls and improvements in transfer ability.
Evaluation
Pain? During assessment, patient scored _ on the Berg Balance Scale indicating a _ risk for falls. Patient ambulated _ft in 6 minutes on the 6 MWT with _ which is below patient’s age-related normative value and indicative of reduced activity tolerance. Patient able to complete _ sit to stands during the 30 sec Chair Stand Test indicating reduced LE functional strength which is below patient’s age-related normative value and contributing to difficulties with functional transfers and going from sitting to standing from low chairs. Patient demonstrates impaired gait causing reduced stability during ambulation increasing risk for falls. Patient demonstrates poor safety awareness indicating a risk for falls. Patient requires skilled physical therapy to address listed deficits required for patient to return to PLOF.
D Env: Patient has modifications in apartment of facility including raised toilet seat, grab bars in bathroom, walk-in shower with shower seat, and moveable shower head. Patient ambulates with rollator / front-wheeled walker and also uses WC when fatigued. Based on evaluation, patient is equipped with appropriate AD at this time. Patient has children in the area who are involved in her medical care and assist as needed. Patient receives assistance as needed from caregivers at facility for various tasks such as: medication management, meal preparation, and housekeeping.
P Res: Patient lives alone in apartment of ALF / ILF partaking in facility-sponsored events and activities, requiring assistance as needed from caregivers at facility for various tasks such as: medication management, meal preparation, mobility assistance, and housekeeping.
Balance precautions include high fall risk.
D Plan: Upon discharge, patient will demonstrate improvements in static and dynamic balance, pain reduction, LE and core strength, activity tolerance, requiring less assistance from staff, and safety awareness. Patient will be discharged to ALF / ILF where they will live alone in apartment and will partake in facility-sponsored events/activities, requiring assistance as needed from caregivers at facility for various tasks such as: medication management, meal preparation, mobility assistance, and housekeeping.
Patient's willingness to participate in skilled physical therapy and motivation to reach goals.
LE MMT: hip flex (R= /5, L= /5) hip ext (R= /5, L= /5), hip abd (R= /5, L= /5), hip add (R= /5, L= /5), hip ER (R= /5, L= /5), hip IR (R= /5, L= /5), knee ext (R= /5, L= /5), knee flex (R= /5, L= /5), DF (R= /5, L= /5), PF (R= /5, L= /5)
Berg Balance Scale: /56
6MWT: _ ft with rollator / FWW and CGA
30 sec CST: _x from standard height chair with / without use of B UE
1RM (converted to 55% of pt’s 1RM): hip flex: lbs (55%= lbs), hip IR:
lbs ( lbs), hip ER: lbs ( lbs), knee ext: lbs ( lbs), standing hip flex: lbs (
lbs), standing hip abd: lbs ( lbs), standing knee flex: lbs ( lbs), standing
hip ext: lbs ( lbs)
Evaluation Complexity:
Low complexity evaluation performed. Patient with a history of no personal factors and comorbidities that impact the plan of care. Examination of body systems using standardized tests and measures addressing 1-2 elements (body structures: low back, B hips, B knees, B ankles and functions, activity limitations, and participation restrictions: difficulty ambulating, difficulty with sit to stands, difficulty performing functional transfers, difficulty with bed mobility). Results of standardizes tests (6MWT, Berg Balance Scale, MMT, 30 sec CST) show (reduced activity tolerance, increased risk for falls, reduced LE functional strength). A clinical presentation with stable and uncomplicated characteristics. Clinical decision making of low complexity using standardized patient assessment instrument and measurable assessment of functional outcome.
Moderate complexity evaluation performed. Patient with a history of 1-2 personal factors (_) and/or comorbidities (_) that impact the plan of care. Examination of body systems using standardized tests and measures addressing 3 or more elements (body structures: low back, B hips, B knees, B ankles and functions, activity limitations, and participation restrictions: difficulty ambulating, difficulty with sit to stands, difficulty performing functional transfers, difficulty with bed mobility). Results of standardizes tests (6MWT, Berg Balance Scale, MMT, 30 sec CST) show (reduced activity tolerance, increased risk for falls, reduced LE functional strength). A clinical presentation that is evolving with changing characteristics. Clinical decision making of moderate complexity using standardized patient assessment instrument and measurable assessment of functional outcome.
High complexity evaluation performed. Patient with a history of 3 or more personal factors (_) and/or comorbidities (_) that impact the plan of care. Examination of body systems using standardized tests and measures addressing 4 or more elements (body structures: low back, B hips, B knees, B ankles and functions, activity limitations, and participation restrictions: difficulty ambulating, difficulty with sit to stands, difficulty performing functional transfers, difficulty with bed mobility). Results of standardizes tests (6MWT, Berg Balance Scale, MMT, 30 sec CST) show (reduced activity tolerance, increased risk for falls, reduced LE functional strength). A clinical presentation with unstable and unpredictable characteristics. Clinical decision making of high complexity using standardized patient assessment instrument and measurable assessment of functional outcome.
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