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Defensible Documentation Examples

Example 1: Outpatient Clinic Patient History

Date: March 8, 2019

Mr. S. is a 67 yo man with L sh pain following a fall 3 days ago. He was referred by his PCP.

PMH: HTN, smoker 21.5 pack-years

Surgical hx: nose melanoma removal 3/2003

Meds: Acebutolol (beta blocker)

Imaging: Xray indicates no fx

Social: Retired, lives at home with wife

_______________________________________________________________________________________________________________________________

Example 2: Acute Care Hospital Initial Examination

Date: November 29, 2018

Heart rate: 108

RR: 14

Pain: 5/10

ROM: WNL

MMT: global weakness

FIM

Transfers

Admission

I. Bed, Chair, Wheelchair

3 Moderate Assist (Subject = 50%+)

J. Toilet

3 Moderate Assist (Subject = 50%+)

K. Tub, Shower

2 Maximal Assist (Subject = 25%+)

Locomotion

L. Walk/Wheelchair

3 Moderate Assist (Subject = 50%+)

M. Stairs

1 Total Assist (Subject = less than 25%)

Motor Subtotal Score

12

_______________________________________________________________________________________________________________________________

Example 3: Outpatient Clinic Re-Examination

Date: June 10, 2018

Reason for re-examination: Ms. K has experienced a change in status. She presents with worsening low back pain symptoms with new onset leg tingling and tripping while walking.

Pain: 4/10

Neurological screen:

DTR - R achilles 1+

SLR Test - + R

Tests:

Oswestry Low Back Pain Disability Questionnaire = 54%; severe disability

_______________________________________________________________________________________________________________________________

Example 4: Outpatient Treatment

97140 Manual Therapy Techniques - 1 unit

Joint and soft tissue mobilization to cervical spine and periscapular area.

97112 Neuromuscular re-ed - 1 unit

PNF UE diagonal bilateral x 10

97110 Therapeutic exercise - 1 unit

PROM flexion, IR, ER 2 sets x 10 reps

_______________________________________________________________________________________________________________________________

Example 5: Home Health Treatment

97535 Self Care/Home Management Training - 1 unit

Patient education on safe mobility using AD.

97116 Gait Training - 2 units

Ambulation with walker 25’ x 2. Practiced transfers bed and chair to walker.

_______________________________________________________________________________________________________________________________

Example 5: Outpatient Plan of Care

Goals:

In 3 months Mrs. P will increase quadricep strength 5/5.

In 3 months Mrs. P will have full knee range of motion.

In 3 months Mrs. P will run 0.25 miles pain free.

Mrs. P will benefit from skilled PT services 2 x week for 12 weeks to support return to recreation. Intervention will include modalities, therapeutic exercise and therapeutic activities.

_______________________________________________________________________________________________________________________________

Example 6: Home Health Plan of Care

Goals:

In 2 months Mr. R will independently transfer from his bedside to the toilet.

In 2 months Mr. R will maintain standing balance for 30 seconds with minimal sway.

In 2 months Mr. R will perform his home program with visual supports.

Mr. R will benefit from skilled PT services 2-3 times per week for 8 weeks to improve his strength, balance, transfers, and mobility.

_______________________________________________________________________________________________________________________________

Example 7: Outpatient Clinic Discharge Visit

Date: March 21, 2019

Ms. K has been receiving outpatient PT services 1 time per week for the past 8 weeks. She has been seen at this clinic for 32 weeks total following R ACL repair surgery on July 2, 2018. Tx has focused on fxnal CKC strengthening, plyometric exercise, neuromuscular re-ed and HEP management. Ms. K has met the following goals and is appropriate for D/C.

Ms. K will demonstrate 5/5 quad strength.

Ms. K will maintain full active knee ROM.

Ms. K will walk with 0/10 pain.

Ms. K will perform her HEP independently.

Ms. K will continue her HEP and follow-up with her physician as needed.

Ryan Curry, PTA

DMU Timestamp: April 30, 2019 18:47





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