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
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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
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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
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