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PHYSICAL THERAPY CARE PLAN - Home Health …

PHYSICAL THERAPY care PLANINTERVENTIONSL ocator #21 EvaluationTeach hip safety precautionsBalance training /activitiesPulmonary PHYSICAL TherapyUltrasound to _____ at _____ x _____ minEstablish/ upgrade home exercise program Copy given to patientTeach safe/effective use of adaptive/assistdevice (specify)Teach safe stair climbing skillsCopy attached to chartElectrotherapy to _____ for _____ minPatient/Family educationProsthetic training Teach fall safetyTherapeutic exerciseTENS to _____ for _____ minPulse oximetry PRNT ransfer training with/without assistanceFunctional mobility trainingHeat/Cold to _____ for _____ minGait training with/without assistanceTeach bed mobility skillsNote: Each modality specify frequency, duration, amount and specify location:SHORT TERM GOALSL ocator #22 Gait will increase tinetti gait score to _____ / 12 within _____ needed:YesPatient/Caregiver aware and agreeable to POC:No (explain):PoorREHAB POTENTIAL:ExcellentFairGoodPlan developed by:DateTherapist Name/Signature/titlePhysician signature:DatePlease sign and return promptly, if applicableOriginal - Patient Chart Copy - Patient's

PHYSICAL THERAPY CARE PLAN INTERVENTIONS Locator #21 Evaluation Balance training /activities Teach hip safety precautions Pulmonary Physical Therapy Ultrasound to _____ at _____ x _____ min

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Transcription of PHYSICAL THERAPY CARE PLAN - Home Health …

1 PHYSICAL THERAPY care PLANINTERVENTIONSL ocator #21 EvaluationTeach hip safety precautionsBalance training /activitiesPulmonary PHYSICAL TherapyUltrasound to _____ at _____ x _____ minEstablish/ upgrade home exercise program Copy given to patientTeach safe/effective use of adaptive/assistdevice (specify)Teach safe stair climbing skillsCopy attached to chartElectrotherapy to _____ for _____ minPatient/Family educationProsthetic training Teach fall safetyTherapeutic exerciseTENS to _____ for _____ minPulse oximetry PRNT ransfer training with/without assistanceFunctional mobility trainingHeat/Cold to _____ for _____ minGait training with/without assistanceTeach bed mobility skillsNote: Each modality specify frequency, duration, amount and specify location:SHORT TERM GOALSL ocator #22 Gait will increase tinetti gait score to _____ / 12 within _____ needed:YesPatient/Caregiver aware and agreeable to POC:No (explain):PoorREHAB POTENTIAL:ExcellentFairGoodPlan developed by:DateTherapist Name/Signature/titlePhysician signature:DatePlease sign and return promptly, if applicableOriginal - Patient Chart Copy - Patient's Home ChartPATIENT NAME - Last, First, Middle InitialID#ADDITIONAL SPECIFIC THERAPY GOALSL ocator #22 Note.

2 Each modality specify location, frequency, duration, and ExpectationSHORT TERMLONG TERMTime FrameTime FrameTherapeutic massage to _____ x _____ minGENERALWill improve gait requiring ____ to _____ from _____ to _____ within ____ MOBILITYPt. will be able to turn side (facing up) to lateral (left/right) within ____ will be able to butt scoot within _____ will be able to sit up with/without assistance _____ within _____ increase tinetti balance score to _____/16 within _____ will be able to reach steady static/dynamic sitting/standing balance with/without assistance _____ within _____ weeksTRANSFERPt. will be able to transfer from _____ to _____ with/without assistance _____ within ____ STRENGTHPt. will be able to hold weigh _____ lb within _____ will decrease from ____/10 to ____ /10 within _____ will be able to oppose flexion or extension force over _____ within _____ will increase ROM of _____ by _____ degrees flexion/extension within _____ will be able to use _____ with/without assistance to _____ feet within _____ will be able to propel wheel chair _____ feet within _____ will be established and SURFACEPt.

3 Will be able to climb stair/uneven surface with/without assistance _____ steps #_____ within _____ will increase tinetti gait score to _____ / 12 within _____ improve gait requiring ____ to _____ from _____ to _____ within ____ MOBILITYPt. will be able to turn side (facing up) to lateral (left/right) within ____ will be able to lie back down within _____ will be able to sit up independently _____ within _____ increase tinetti balance score to _____/16 within _____ will be able to reach steady static/dynamic sitting/standing balance with/without assistance _____ within _____ weeksTRANSFERPt. will be able to transfer from _____ to _____ with/without assistance _____ within ____ STRENGTHPt. will be able to hold weigh _____ lb within _____ will decrease from ____/10 to ____ /10 within _____ will be able to oppose flexion or extension force over _____ within _____ will increase ROM of _____ by _____ degrees flexion/extension within _____ will be able to use _____ independently to _____ feet within _____ will be able to self propel wheel chair _____ feet within _____ will be able to finalize and demonstrated to follow up SURFACEPt.

4 Will be able to climb stair/uneven surface with/without assistance _____ steps #_____ within _____ will be able to self reposition within _____ TERM GOALSINITIALUPDATEDDISCHARGE PLANS DISCUSSED WITH:Patient/FamilyPhysicianOther (specify) care ManagerOTSNSTP hysicianCARE COORDINATION:Other (specify)MSWAidePTAAPPROXIMATE NEXT VISIT DATE: plan FOR NEXT VISITD iagnosis/ Reason for PT:Frequency and Duration:ONSET:OTHER INTERVENTION/TREATMENT:If applicable, portion of plan of care assigned to a PTA was discussed, explained to the PTA: SAMPLEPHYSICAL THERAPY //DATE OF SERVICETIME INOUTOBJECTIVE DATA TESTS AND SCALES PRINTED ON OTHER REASON:TYPE OF EVALUATIONN eeds assistance for all activitiesResidual weaknessFinalInitialRequires assistance to ambulateConfusion, unable to go out of home aloneInterimSevere SOB, SOB upon exertionUnable to safely leave home unassisted//SOC DATEM edical restrictionsDependent upon adaptive device(s)(if Initial evaluation , complete PHYSICAL TherapyOther (specify) care plan )Chest PTTransfer TrainingTherapeutic ExerciseGait TrainingHome Program InstructionEvaluationPT ORDERS:Other.

5 Prosthetic TrainingElectrotherapyMuscle Re-educationUltrasoundPERTINENT BACKGROUND INFORMATIONTREATMENT DIAGNOSIS/ PROBLEMONSETMEDICAL HISTORYPRIOR/CURRENT LEVEL OF FUNCTIONIF racturesHypertensionCardiacCancerDiabete sInfectionImmunosuppressedRespiratoryPri or level of function (ADL/IADL) Specify: (ADL/IADL On Problematic Areas)OsteoporosisOpen woundOther (specify)LIVING SITUATIONC urrent level of function (ADL/IADL) Specify: (ADL/IADL On Problematic Areas)AbleCapableWilling caregiver availableLimited caregiver support (ability/willingness)No caregiver availableHOME SAFETY BARRIERS:PERTINENT MEDICAL/SOCIAL HISTORY AND/ORPREVIOUS THERAPY RECEIVED AND OUTCOMESC lutterThrow rugsNeeds grab barsNeeds railingsSteps (number/condition)Other (specify)BEHAVIOR/MENTAL STATUSA lertOrientedCooperativeImpaired JudgementConf usedMemory deficitsOther (specify)PAININTENSITY: 0 1 2 3 4 5 6 7 8 9 10 LOCATION:AGGRAVATING /RELIEVING FACTORS:VITAL SIGNS/CURRENT :Edema:Sensation:Muscle Tone:Posture:Skin Condition:Communication-Vision:Hearing:E ndurance:Orthotic/ Prosthetic Devices:PART 1 PART 2 TherapistClinical Record--ID#PATIENT/CLIENT NAME - Last First, Middle InitialPHYSICAL THERAPY evaluation //MEDICAL PRECAUTIONS:Assistive Device:Needs:Has:PAIN TYPE (dull, aching, etc):PATTERN (Irradiation).

6 EVALUATIONRE-EVALUATIONCruz & Sanz Health Services, SAMPLEPHYSICAL THERAPY (Cont'd.)AREAASSISTIVE DEVICES/COMMENTSTASKACTIONASSISTSCORELef tRoll/TurnSit/ SittingDynamic SittingStatic StandingDynamic StandingPropulsionPressure ReliefsFoot EXTREMITIESKneeFlex/ExtendAnklePlant/Dor sFootInver/EverW/C SKILLSOBJECTIVE DATA TESTS AND SCALESFUNCTIONAL RANGE OF MOTION (ROM) SCALEMANUAL MUSCLE TEST (MMT) MUSCLE STRENGTHGRADEDESCRIPTIONDESCRIPTIONGRADE N ormal functional strength - against gravity - full active functional active functional active functional active functional than 25%.54321 Good strength - against gravity with some strength - against gravity - no resistance - safety strength - unable to move against strength - slight muscle contraction - no - no active muscle able and does task cue (VC) only assist (SBA)-100% patient/client assist (Min A)-75% patient/client assist (Max A)-25% - 50% patient/client dependent-total care /supportBALANCE SCALE (sitting - standing)DESCRIPTIONGRADEI ndependent543210 Verbal cue (VC) only assist (SBA)-100% patient/client assist (Min A)-75% patient/client assist (Max A)-25% patient/client dependent for :IndependentUnableMax.

7 AssistSURFACES:DISTANCE:LevelUnevenStair s (number/condition)PWBNWBTDWBWBATFWBWEIGH T BEARING STATUS:Hemi-walkerWalkerASSISTIVE DEVICE(S):Wheeled walkerCaneCrutchesQuad caneOther (specify)QUALITY/DEVIATIONS:PATIENT INFORMATIONMED. RECORD #:PATIENT'S NAME:THERAPIST'S//SIGNATURE/TITLEDATEMUS CLE STRENGTH/FUNCTIONAL ROM EVALFUNCTIONAL INDEPENDENCE/BALANCE EVALLOWER EXTREMITIESR ightROMSTRENGTHR ightLeftBED MOBILITYFUNCTIONAL INDEPENDENCE SCALE (bed mobility, transfers, W/C skills)NORMATIVE DATA FOR JOINT MOTION (ROM)ooooooooooooooooooooooooooPHYSICIAN 'SSIGNATURE//DATE* If no changes made to Initial plan of care , MD signature no CHANGEFOR RE- evaluation USE ONLY:IF A PREVIOUS plan OF care WAS ESTABLISHED, THEN IT WILL:Cruz & Sanz Health Services, SAMPLEPHYSICAL THERAPYWEEKLY SUMMARY REPORTB edrest/BRPT ransfer Bed/ ChairComplete BedrestUp as ToleratedACTIVITIES PERMITTED.

8 No WeightbearingIndependent at HomeNo RestrictionsPartial WeightbearingFull WeightbearingHoyer LiftStair ClimbingCaneCrutchesWalkerWheel ChairOtherDisorientedComatoseAgitatedLet hargicForgetfulOrientedDepressedMENTALST ATUS:OtherAmbulates with AssistSevere SOBBed boundUses W/C, Walker, CaneHOMEBOUND STATUSDUE TO:Severe WeaknessUp in Chair with max assistParalysisUnable to walkBalance/Gait - UnsteadyOtherSubjective Comments:Specific Safety Issues Addressed:INSTRUCTED:TREATMENT RENDERED (If Pt/CG. instructed. see response below) ExercisesAdaptive EquipmentTransfer TrainingGait TrainingEMS, Ultrasound, Massages, Hot/Cold PackEnergy ConservationOtherPLAN OF care : PROBLEM - ACTION/PROGRESS TOWARD GOALS - PT'S/CG's RESPONSE TO : plan for Next Visit:Next Scheduled Visit Date:Additions to plan of CarePatient NameDate:Therapist Name/Signature/TitleCruz & Sanz Health Services, SAMPLEPHYSICAL THERAPYREVISIT NOTEVITAL SIGNS: Temperature:Pulse:Irregular Respirations:RegularIrregularRegularStan dingSitting LeftBlood Pressure: RightLying//Location(s)PAIN:NoneSameWors eImprovedOriginIntensity 0- 10 Relief measuresDurationOtherTYPE OF VISIT:HOMEBOUND REASON.

9 Needs assistance for all activitiesResidual weaknessRevisitRequires assistance to ambulateConfusion, unable to go out of home aloneRevisit and Supervisory VisitSevere SOB, SOB upon exertionUnable to safely leave home unassistedOther (specify)Medical restrictionsDependent upon adaptive device(s)Other (specify)TREATMENT DIAGNOSIS/PROBLEM AND EXPECTED OUTCOMES: evaluation (B1) PHYSICAL THERAPY INTERVENTION/INSTRUCTIONS (Mark all applicable with an ''X''.)Copy given to patientCopy attached to chartSAFETY ISSUESROM:Obstructed pathwaysHome environmentStairsUnsteady gaitVerbal cues requiredEquipment in poor conditionBathroomCommodeOthers:TEACHING, TRAINING, RESPONSE TO INSTRUCTIONS:Reviewed/Revised with patient plan :To CGFamilyTo PatientOther: _____If revised, specifyINSTRUCTION ABOUT:Treatment, EquipmentNeed for referral (specify)TEACHING/TRAINING OFPATIENT/FAMILY RESPONSE TO INSTRUCTIONS:(specify)DISCHARGE PLANS DISCUSSED WITH:Patient/FamilyCARE plan UPDATED?

10 NoYes (specify, complete Modify Order)PhysicianOther (specify) care ManagerBILLABLE SUPPLIES RECORDED?N/AYes (specify)If PT assistant/aide not present, specify date he/she wasPT/PTAOTSLPP hysicianCARE COORDINATION://contacted regarding updated care plan :HHAO ther (specify)MSWSNSIGNATURES/DATESxComplete TIME OUT prior to signing (if applicable, optional if weekly is used)Therapist (signature/title)PART 1 - Clinical RecordPART 2 - TherapistID#PATIENT NAME - Last, First, Middle InitialSTRENGTH:BALANCE:MOBILITY/TRANSFE R/AMBULATION: plan FOR NEXT VISIT:Establish/Upgrade home exercise programPatient/Family educationTherapeutic exercise (B2)Transfer training (B3)Gait training (B5)Balance training/activitiesTENSU ltrasound (B7)Electrotherapy (B8)Prosthetic training (B9)Preprosthetic trainingFabrication of orthotic device (B10)Muscle re-education (B11)Management and evaluation of care plan (B12)Pulmonary PHYSICAL THERAPY (B6)Cardiopulmonary PTPain ManagementCPM (specify)Functional mobility trainingTeach bed mobility skillsTeach hip safety precautionsTeach safe stair climbing skillsTeach safe/effective use of adaptive/assistdevice (specify)Other:TIME INOUTO2 saturation ____ % (when ordered)DATE OF SERVICE:Modality used LocationF


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