Physical Therapy Patient Assessment - Fall 2024 - Tidewater Community College

TIDEWATER COMMUNITY COLLEGE PTA PROGRAM VA BEACH CAMPUS PTH 105 -- [Unit 7 Lab] -- [HO\#4] -- [Sample Functional Assessment Documentation Fall 2024] **Learner Objective:** D3. Document a functional assessment in the medical record. 11/10/22 [PT Initial Evaluation:] 56 yo male, 2 weeks s/p (R...

TIDEWATER COMMUNITY COLLEGE PTA PROGRAM VA BEACH CAMPUS PTH 105 -- [Unit 7 Lab] -- [HO\#4] -- [Sample Functional Assessment Documentation Fall 2024] **Learner Objective:** D3. Document a functional assessment in the medical record. 11/10/22 [PT Initial Evaluation:] 56 yo male, 2 weeks s/p (R) CVA with (L) hemiparesis. Currently at Maryview ARU for intensive rehab -- PT order is for BID x 3 weeks for functional mobility training to allow the patient to return home with his wife. [Bed mobility]: - Cephalad ↔ Caudad: min (A) - Rolls (L) ↔ (R): mod (A) - Supine → sit to (L): mod (A) to manage upper body - Sit → supine to (L): min (A) [Transfers]: after training, performs stand- step to (R), W/C to bed with gait belt req. mod (A) to assume standing and for balance [Ambulation]: after training, ambulates 20' on tiled surface with LBQC (R) and gait belt req. mod (A) for correct LE sequence and to safely place AD. Patient easily SOB and lacks endurance to ambulate longer distances. [Stairs]: not tested at this time [Balance] - [Static and dynamic sitting]: WNL - [Static standing]: accepts slight challenges (3+/5): all directions - [Dynamic standing]: unable to move out of BOS without falling [STGs (2 weeks)] 1. Patient will demonstrate (I) with all aspects of bed mobility 2. Patient will transfer to all surfaces with CG 3. Patient will ambulate [\>] 75 feet with SBQC req. CG to allow him to get to the dining room for meals [LTGs (3 weeks)] 1. Patient will transfer to all surfaces including car (I) so patient can return home safely 2. Patient will (I) ambulate \> 100 feet with least restrictive AD to allow him to return home 3. Patient will negotiate 4 steps with a right rail with CG to allow patient to safely enter home upon D/C [Plan]: Pt will be seen BID in inpatient rehab unit for functional mobility training to include bed mobility, transfer training, gait training, neuromuscular reeducation, balance training, and patient education to allow the patient to return home with wife. Melanie Basinger, PT, DPT, MS PT Tx \#5: 11/15/22 S: Patient remains in good spirits with his wife attending therapy sessions on a daily basis. Wife expresses concern about getting her husband into the house due to having no railing on the front steps. Patient is eager to go home and thinks he won't have any difficulty except he shares his wife's concern about the stairs. O: [Functional mobility Reassessment]: After training, patient's functional status is as follows: 1. [Bed mobility]: - Cephalad ↔ Caudad: (I) - Rolls (L) ↔ (R): (I) - Supine → sit to (L): min (A) to manage upper body - Sit → supine to (L): (I) Gait belt used for all standing activities (items \#2-5): 2. [Transfers]: performs stand-step bed to W/C to (R) using SBQC (R), with CG for occasional LOB 3. [Ambulation]: ambulates 100' on level tiled surface with SBQC (R) with CG. Noted 2 episodes of loss of balance with inability to self-correct. Slight SOB noted after ambulation with RR of 22 breaths/min. 4. [Stairs]: negotiates 4 steps ↑↓ using step to step pattern using (R) rail to ↑ and (R) SBQC to ↓, requires min (A) for stability and VCs for correct step sequence. 5. [Balance] - [Static and dynamic sitting]: WNL - [Static standing]: accepts min challenges (4-/5): P→ A and (L) → (R) accepts slight challenges (3+/5): A→ P and (R)→ (L) - [Dynamic standing]: moves min distances out of BOS 6. [Patient Education]: Wife instructed in proper guarding of husband on stairs -- needs more practice before she is safe. Provided with the name of contractor to install rails for steps leading into house. A: Patient is making excellent progress since beginning PT. He has achieved STG \#2, 3 and partially achieved STG \#1. He is now able to transfer to all surfaces and walk 100' using SBQC with just CG. He is still having difficulty getting out of bed due to weakness in his left upper body limiting his ability to push himself up into a sitting position. Otherwise he is (I) with all other aspects of bed mobility. Patient is progressing toward LTGs and is able to negotiate 4 steps with min (A). Expect patient will achieve (I) in transfers and ambulation during his during final week of rehab allowing him to safely return home with his wife. P: Progress with stair negotiation to promote (I). Add SLS balance activities and stepping over items to improve balance. Practice outdoor ambulation on grass, curbs, and ramps in preparation for DC home. Melanie Basinger, PT, DPT, MS