PHYSICAL THERAPY CARE PLAN - PN System

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.

2 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: 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.

3 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. 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.

4 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.

5 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.

6 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.

7 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):EVALUATIONRE-EVALUATIONCru z & 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%.

8 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.

9 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.

10 Cruz & Sanz Health Services, SAMPLEPHYSICAL THERAPYWEEKLY SUMMARY REPORTB edrest/BRPT ransfer Bed/ ChairComplete BedrestUp as ToleratedACTIVITIES PERMITTED: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.)