PRIOR LEVEL OF FUNCTION
Prior to the current exacerbation of the illness, the patient needed no assistance (was independent) with basic activities of daily living (BADLs) including household mobility. IND WITH GETTING IN/OUT OF HOUSE, IND WITH TRANSFERS, GROOMING, BATHING, LAUNDRY, SHOPPING, TRANSPORTATION.
PAIN
LOWER BACK AT 4/10; WORST WITH COLD/RAINY WEATHER, WEIGHT BEARING, TRANSFERS; BETTER WITH REST, MEDICATION, DIVERSION
Intervention GAIT
PATIENT AMBULATED 250 FT IND WITH WALKER. IMPROVED USE OF AD. PATIENT INSTRUCTED IN PROPER POSTURE, KEEP BACK STRAIGHT, SAFETY/PROPER USE AT STAIRS AND FALL PRECAUTIONS.
INTERVENTION EXERCISES
SKILLED PT DISCHARGE ASSESSMENT COMPLETED. PATIENT PERFORMED INSTRUCTED IN HOME EXERCISE PROGRAM
Intervention BALANCE
PATIENT INSTRUCTED TO CONT USE OF AD, FALL SAFETY, REMOVE THROW RUGS AND REVIEWED HOME EXERCISES FOR BALANCE.
DC Summary
SUBJECTIVE
PATIENT STATED HER LEGS FEEL WEAK AND SHE GETS TIRED EASILY.
MMT
GROSS MUSCLE STRENGTH IN RIGHT HIP 4+/5 LEFT HIP 4+/5 IN RIGHT KNEE 4+/5 LEFT KNEE 4+/5 IN RIGHT ANKLE 5/5 LEFT ANKLE 5/5
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SUBJECTIVE
PATIENT STATED HER LEGS FEEL WEAK AND SHE GETS TIRED EASILY.
MMT
GROSS MUSCLE STRENGTH IN RIGHT HIP 4+/5 LEFT HIP 4+/5 IN RIGHT KNEE 4+/5 LEFT KNEE 4+/5 IN RIGHT ANKLE 5/5 LEFT ANKLE 5/5
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DC SUMMARY
NUMBER OF PT VISITS: START DATE END DATE Focus of care STRENGTH 30 SEC CHAIR TEST
TINNETI BALANCE TINNETI GAITTUG:
