Short-Term Rehab Cheat Sheet (Casamba)

 

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 independence. Patient able to ambulate _ft with _ and _. Patient performed Timed Up and Go in _ sec with FWW and CGA indicating reduced stability with gait. Patient stated pain in _ contributing to deficits. Patient able to complete _ sit to stands with/without use of BUE for push-off 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>standing from low chairs. Patient demonstrates impaired bed mobility. Patient demonstrates impaired gait causing reduced stability during ambulation increasing risk for falls. Patient demonstrates poor safety awareness with AD and transfers increasing chances for falls. Patient requires skilled physical therapy to address listed deficits required for patient to return to PLOF.

Or

Therapy necessity for improved balance, strength, functional activity tolerance, and gait. Without skilled PT, pt at risk for further decline in functional mobility.

Prior Residence and Living Arrangement

Patient’s prior living situation: lived at double-level home, 2 STE home with handrails on L and R, main bedroom on 2^nd level, staircase to 2^nd level has handrail on the R, denies having any AD in the home, walk-in shower, tub-shower. Patient has children in the area who was involved in patient’s medical care and provided assistance as needed.

Discharge Environmental Factors/Social Support

Patient with family support at home including home management, medication management and meal preparation.

Previous Therapy

Patient received skilled physical therapy services during hospitalization.

Precautions

Example: balance precautions include high fall risk. Wounds to B feet causing pain with weight bearing. Safety precautions - needs 24-hour supervision and is at risk of elopement. Functional incontinence d/t inability to get to restroom in time. Impaired cognition.

Discharge Plan

Patient will be discharged to home with home health and family support. Upon discharge from this facility, 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.

Standardized Tests and Measures

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)
30 sec CST: _x from standard height chair with / without use of B UE
Elderly Mobility Scale: /20
Timed Up and Go: _ sec with rollator

 

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.

Re-evaluation performed. Examination including a review of history and use of standardized tests and measures. Revised plan of care using a standardize patient assessment instrument and/or measurable assessment of functional outcomes.

 

Progress Note

Analysis of Functional Outcomes/Clinical Impression:

Patient has participated and demonstrated improvement with skilled physical therapy. Patient scored _/20 on the Elderly Mobility Scale indicating improvements in safety and independence. Patient able to complete the Timed Up and Go in _ sec indicating improvements in stability with gait. Patient able to ambulate _ft with FWW and CGA which demonstrates greater mobility and activity tolerance compared to when previously measured. 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. Patient demonstrates SBA with bed mobility which is an improvement since initial evaluation.

Skilled Services Provided Since Last Report:

Physical therapy has facilitated static and dynamic balance, bed mobility, proper gait, pain reduction techniques, LE and core strengthening, activity tolerance training and progression, and safety awareness for patient to return to PLOF.  

Patient/Caregiver Training:

Patient has been educated on safety awareness with assistive device during gait, improved gait mechanics for improved stability with gait, cues for proper technique with interventions, as well as importance of physical therapy. Patient has improved in their carryover with education and demonstrating increased safety awareness and gait mechanics.

Remaining Functional Deficits/Underlying impairments:

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, gait mechanics, bed mobility, and safety awareness for improvements in patient’s ability to return to PLOF and reduce risk for falls.

Impact of Burden of Care:

Patient has improved in their stability with gait based on TUG, however, remains a fall risk requiring assistance for safety with various functional tasks such as ambulation, transfers, toileting, etc. Patient has demonstrated improvements in activity tolerance based on ambulation distance however still requires assistance due to reduced safety and stability with ambulation.

Updates to Treatment Approach:

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, gait mechanics, and safety awareness are appropriate for this patient. 

 

 

Intervention Assessments:

Therapeutic Exercise:

Assessed patient’s ambulation tolerance and aerobic capacity with ambulation with FWW. Patient ambulated _ft with FWW and required CGA/SBA. Facilitated additional ambulation bout of _ft with FWW and CGA.  

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 level of independence with various functional tasks using the Elderly Mobility Scale.

Assessed patient’s stability with gait based on Timed Up and Go utilizing FWW and requiring CGA. 

Neuro re-education:

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.