brog_train.csv

label,text
0,Discussed with pt HEP and reason for new PT referral  discharge per pt request at this time to grieve.
0,Caregiver was educated to use WC as needed for pt and caregiver safety due to R knee pain and increased difficulty with transfers and ambulation.
1,"Discharged early into treatment plan so unable to make significant improvements, and unable to be evaluated due to unexpected discharge."
0,Patient not showing any signficant progress for the past few weeks.
0,Patient will continue with HEP only and discharge from PT POC as PT management is no longer indicated.
1,Pt was maintaining slow but steady progress of reducing assistance needing for STS transfers to allow for improved safety for CNA staff with patient transfers.
1,Therapist agreeable to DC as patient met or partially met most of his goals.
1,patient has made very good progress throughout POC.
1,She demonstrates less low back and radicular pain overall and improved function mobility.
0,"Patient transitioning to skilled Nursing care due to new open wound on LE, per ALF Nursing director."
0,"Upon discharge, he ambulates up to 1000ft with RW independently, performs transfers independently, and completes comprehensive HEP with HHA assistance."
0,Recommend transition to home health agency to manage medical issues with skilled nursing intervention.
0,"Previously had low back pain 1/10 w/ activity at IE, no reports of pain at DC."
0,Pt was dc to pt will be receiving Med A services
0,"However, she has reached all her functional goals and is no longer in need of PT care."
1,Similar improvement in strength was evident from overall score of 3-/5 to 3+/5/ Tranfer and ambulatory goal was improving with the current ability to perform perform tranfer and ambulating with MOD assist which was MAX assist at initial evaluation.
1,"Pt made progress with skilled PT with improved BLE strength, which helped facilitate consistency with transfers and stability with standing and gait with rollator walker, but gait distance continues to be limited by SOB on 3 L O2 via NC."
1,"Patient is independent with bed mobility, transfers, ambulation without an AD, and stair negotiation."
0,"CG training completed and pt encouraged to amb in room with CG, WW and WC follow."
0,"Pt progress with PT has been limited due to pt reporting she spends time mostly in bed and also shortened PT sessions related to pt anxiety, pt not being ready to begin PT sessions at scheduled time despite phone call prior to sessions."
0,Pt has been sick for the past few weeks and spouse attempted to cancel for a few more weeks.
1,PT has recommended recliner chair with motorized adjustment of height to improve efficiency and pt and CG safety during STS transfers which the pt has been using.
0,She is now in short term rehab.
1,"Pt achieved highest functional level with bed mobility Inde, transfers Inde and ambulation  SBA x 140 ft with 2WW."
1,"Achieved increased LE strength, improved sit to standtransfers, standing balance and gait using Rollator walker."
1,Pt's transfer and ambulation status as improved which agrees with improved LE strength which was evidenced by pt's progression with resistance for her exercises.
1,"During the course of therapy session patient was provided with exercises to improve strength, balance, gait training."
0,Pt has had set backs throughout POC due to multiple infections and illness which has made progress slow.
0,Discussed with patients daughter and due to significant decline in patients mobility and increase in PD symptoms pt is going to get a HHA and continue PT services with HHC at this time.
1,"Pt presented with moderate LE difficulties, Pt able to steadily increase LE strength to allow for improved transfers from standard chair, and to be able to stand from outside porch chair that has a lower surface."
0,patient hence DC
0,Patient no longer requires skilled care and will benefit from continued exercise with independent HEP
0,Pt has been referred to OT services to address B hand function and ADL safety.
1,Client presenting for discharge at time of this visit as he appears to have achieved maximal level of functional potential at this time.
1,Pt has made great progress with improved independence with transfers and increased tolerance for ambulation.
0,Pt was admitted to the hospital with severe stomach pains.
1,"Pt improved CV stamina with all activities, however requires proper pacing and seated rest periods between set of activities to prevent SOB."
0,The patient has had a complicated rehab course with multiple medical issues with a-fib and most recently undergoing eye surgery with limitations on ability to perform standing activities.
1,Pt has achieved PT goals
0,The patient and caregiver have been instructed in strategies and the patient is a good candidate for discharge at this time.
1,There has been increased LE strength levels from RX to date as reflected by improved FOM test scores that indicate lesser fall risk as well.
0,Patient has maintained his ability to transfers at grab bars and was able to perform minVC pulling self up.
0,Anthony Miron is a 42 y/o male referred to FOX Rehab for PT services with c/o B LE strength deficits resulting from prolonged bedbound status and morbid obesity.
0,Pt.
0,Pt is now appropriate for discharge.
0,The patient is unable to progress further functionally due to impaired cognition due to progression of PD and dementia.
0,She exhibited decreased mobility including fluctuating bed mobility from independent to max assist or total refusal.
1,Pt demonstrated functional improvements before hospitalization and may be referred back to outpatient PT when pt returns to ALF.
0,"At this time, pt will be discharged from skilled physical therapy due to limited ability to participate in therapy sessions without causing increased chest pain/tightness and SOB."
0,Patient met with a spinal surgeon who has requested patient to stop all exercises at this time.
0,Pt given HEP to continue to progress condition.
0,"Patient continues to have chronic pain, however, pain level has decreased."
0,The patient was discharge from PT due patient's request.
0,Pt discharged due to not being able to make any progress.
0,Recommended to ambulate with his home health aid everyday.
0,Patient has shown some progress in goals.
1,Pt has achieved PT goals
0,"For both FOMS, compared to age matched norms, pt continues to be positive fall risk."
0,Pt had a medical issue and was taken to the hospital last week.
0,In hospital recovering - PT will resume when able.
1,Pt will benefit from cont participation w/ HEP to maintain strength & fxnl gains to prevent future decline.
0,He will be followed via reconnect call to determine his permanent housing area and if therapy needs are being met.
0,Patient would require SBA on her transfers and ambulation for safety.
0,Dx UTI.
1,patient has made great progress since SOC.
1,"No further skilled PT required, Pt has reached her max potential"
0,"Discharged at this time, and plan to continue services when returning to FOX."
1,Patient demonstrates improvements in functional mobility and balance as measured via BBS.
0,"Pt has been seen for 10 visits of PT to address her neck pain, neck stiffness, and shoulder and postural weakness."
0,Patient has reached max functional function and is at plateau stage.
1,Gains achieved in pt with L LE pain answered arthritis.
0,DC PT.
0,"Pt and daughter performed car transfers with good success and understanding of WC, body and UE placement for safety."
0,Ambulation was recently progressed to outdoors with SPC.
0,Therapist will maintain contact with NSM and pt's family re delivery plans and may reopen case if caregiver education on w/c management and positioning is necessary.
0,Informed by Anthology that the patient may be switched to medicare A.
0,"Pt still needs supervision with stand pivot transfers, mostly outdoors, due to cognitive impairments."
0,PT stressed continuation of exercises before planned surgery to place shunt due to hydrocephalus to prepare her body and to minimize weakness.
0,"Pt was non-compliant with HEP and did not follow recommendations for walking program, car transfers and use of W/C out in community."
0,Pt continues to ambulate with significantly increased pace and forward flexed posture despite consistent training.
0,Thank you for the opportunity to participate in her skilled PT care.
0,Pt refused to cont Therapy and requested D/C.
1,"Patient has been making steady progress toward goals established at initial evaluation while working on improving bilateral lower extremities strength,  balance, standing tolerance, overall activity tolerance, improving safety technique and decreasing level of assistance required with transfers, improving ambulation distance and safety with assistive device."
0,"Pt also had difficulty with eyes closed on unaltered surfaces, affecting ability to ambulate to bathroom at night."
0,Education was done for caregivers regarding disease management and equipment.
0,Pt has reached max benefit from skilled PT intervention at this time.
1,"Pt cont limitations with balance activities, as shown in FOM (TUG), however has greatly improved."
0,RN staff at SLC aware of when to refer back to Fox therapy services in the future if pt is appropriate.
1,Ongoing training has been provided to improve patient's tolerance.
1,Pt able to make slight improvements to endurance and incorporating updated HEP to maximize benefits after discharge.
0,She is modified indpendent in gait and transfers with her rollator with staff supervising.
0,There's no further skilled PT needed at this time.
0,Will return to PT once able.
0,Pt.
0,"Minimal strength deficits remain throughout hip girdle, as well as limited hip extension ROM due to chronic hip OA."
0,"Patient is an active resident of assisted living facility with nursing assistance for medication pass only, housekeeping and three meals a day."
1,Patient demonstrated good progress toward all goals and currently maintained at set up assistance level of function for 2 months with 5 visits from PT.
1,The patient has achieved all goals for functional outcome measures.
1,"Pt has been able to ambulate for four trials of 40ft requiring only minimal physical assistance, demonstrating improved strength and NM control."
0,"Pt presented with instability and feet dragging when ambulating in multiple directions, and on 4 square step test."
1,"Pt no longer requires skilled PT, he has (I) HEP to follow to continue to improve his transfers and gait in home with cane- he will also walk out to mailbox daily"
0,"Client to be discharged on this date d/t lack of participation, lack of motivation, and lack of progress."
0,"Pt had abrupt discharge due to hospitalization for kidney stone and blood in urine, and has returned home with VNA services."
0,Pt's status fluctuates and when appropriate can ambulate with caregivers.
1,"Although improved, pt will benefit from being compliant with HEP in order to maximize progress."
1,"She has improved her gait speed, endurance, and ambulation ability and is now independent with HEP to maintain gains."
0,Pt will be discharged from Fox at this time.
0,Exercises include: Seated Ankle Circles - 10 reps - 2 sets - 1x daily - 7x weekly Bilateral Long Arc Quad - 10 reps - 2 sets - 1x daily - 7x weekly Seated Small Alternating Straight Leg Lifts - 10 reps - 2 sets - 1x daily - 7x weekly Seated Ankle Pumps - 10 reps - 2 sets - 1x daily - 7x weekly Seated March - 10 reps - 2 sets - 1x daily - 7x weekly Seated Long Arc Quad - 10 reps - 2 sets - 1x daily - 7x weekly Seated Heel Raise - 10 reps - 2 sets - 1x daily - 7x weekly Standing Hip Abduction with Counter Support - 10 reps - 2 sets - 1x daily - 7x weekly Standing Hip Extension with Counter Support - 10 reps - 2 sets - 1x daily - 7x weekly Seated Ankle Dorsiflexion AROM - 10 reps - 2 sets - 1x daily - 7x weekly Seated Hip Abduction with Resistance - 10 reps - 2 sets - 1x daily - 7x weekly Seated Hip Adduction Squeeze with Ball - 10 reps - 2 sets - 1x daily - 7x weekly Seated Knee Lifts with Resistance - 10 reps - 2 sets - 1x daily - 7x weekly Seated Knee Extension with Anchored Resistance - 10 reps - 2 sets - 1x daily - 7x weekly CLX Ankle Dorsiflexion and Eversion - 10 reps - 2 sets - 1x daily - 7x weekly Seated Single Leg Hip Abduction with Resistance - 10 reps - 2 sets - 1x daily - 7x weekly Seated Knee Extension with Resistance - 10 reps - 2 sets - 1x daily - 7x weekly Seated Heel Raise - 10 reps - 2 sets - 5 hold - 2x daily - 5x weekly Seated Toe Raise - 10 reps - 2 sets - 5 hold - 2x daily - 5x weekly Seated Long Arc Quad - 10 reps - 2 sets - 5 hold - 2x daily - 5x weekly Seated March - 10 reps - 2 sets - 5 hold - 2x daily - 5x weekly Seated Shoulder Flexion Full Range - 10 reps - 2 sets - 5 hold - 2x daily - 5x weekly Seated Shoulder Horizontal Abduction with Resistance - Thumbs Up - 10 reps - 2 sets - 2x daily - 5x weekly Seated Shoulder Horizontal Abduction - Palms Down - 10 reps - 2 sets - 2x daily - 5x weekly Standing Hip Abduction with Counter Support - 10 reps - 2 sets - 1x daily - 7x weekly Standing Hip Extension with Counter Support - 10 reps - 2 sets - 1x daily - 7x weekly Standing Knee Flexion with Counter Support - 10 reps - 2 sets - 1x daily - 7x weekly Heel Raises with Counter Support - 10 reps - 2 sets - 1x daily - 7x weekly Heel Toe Raises with Counter Support - 10 reps - 2 sets - 1x daily - 7x weekly Standing March with Counter Support - 10 reps - 2 sets - 1x daily - 7x weekly Narrow Stance with Counter Support - 10 reps - 2 sets - 1x daily - 7x weekly Standing Tandem Balance with Counter Support - 10 reps - 2 sets - 1x daily - 7x weekly Standing Single Leg Stance with Counter Support - 10 reps - 2 sets - 1x daily - 7x weekly Seated Cervical Retraction Protraction AROM - 10 reps - 2 sets - 1x daily - 7x weekly Seated Scapular Retraction - 10 reps - 2 sets - 1x daily - 7x weeklyStanding Isometric Shoulder Extension at Table - 10 reps - 2 sets - 1x daily - 7x weekly Hip Abduction with Resistance Loop - 10 reps - 2 sets - 1x daily - 7x weekly Hip Extension with Resistance Loop - 10 reps - 2 sets - 1x daily - 7x weekly Standing Hip Flexion with Resistance Loop - 10 reps - 2 sets - 1x daily - 7x weekly Seated Hip Abduction with Resistance - 10 reps - 2 sets - 1x daily - 7x weekly Seated Hip Adduction Squeeze with Ball - 10 reps - 2 sets - 1x daily - 7x weekly Seated Knee Lifts with Resistance - 10 reps - 2 sets - 1x daily - 7x weekly Seated Knee Extension with Anchored Resistance - 10 reps - 2 sets - 1x daily - 7x weekly CLX Ankle Dorsiflexion and Eversion - 10 reps - 2 sets - 1x daily - 7x weekly Seated Single Leg Hip Abduction with Resistance - 10 reps - 2 sets - 1x daily - 7x weekly Seated Knee Extension with Resistance - 10 reps - 2 sets - 1x daily - 7x weekly Seated Scapular Retraction - 10 reps - 2 sets - 1x daily - 7x weekly Seated Shoulder Rolls - 10 reps - 2 sets - 1x daily - 7x weekly Seated Shoulder Shrug Circles AROM Backward - 10 reps - 2 sets - 1x daily - 7x weekly Seated Shoulder Flexion - 10 reps - 2 sets - 1x daily - 7x weekly Seated Shoulder External Rotation - 10 reps - 2 sets - 1x daily - 7x weekly Seated Scapular Protraction and Retraction - 10 reps - 2 sets - 1x daily - 7x weekly Seated Scapular Protraction and Retraction - 10 reps - 2 sets - 1x daily - 7x weekly Seated Shoulder Horizontal Abduction - Palms Down - 10 reps - 2 sets - 1x daily - 7x weekly Seated Shoulder Extension - 10 reps - 2 sets - 1x daily - 7x weekly  Seated Shoulder Abduction - Palms Down - 10 reps - 2 sets - 1x daily - 7x weekly Seated Shoulder Abduction with Bent Elbow - 10 reps - 2 sets - 1x daily - 7x weekly Seated Bent Over Shoulder Row with Dumbbells - 10 reps - 2 sets - 1x daily - 7x weekly Seated Elbow Flexion with Resistance Under Foot - 10 reps - 2 sets - 1x daily - 7x weekly Seated Shoulder Front Raise with Resistance - 10 reps - 2 sets - 1x daily - 7x weekly Seated Shoulder Horizontal Abduction with Resistance - Palms Down - 10 reps - 2 sets - 1x daily - 7x weekly Low Horizontal Abduction with Resistance - 10 reps - 2 sets - 1x daily - 7x weekly Seated Shoulder Diagonal Pulls with Resistance - 10 reps - 2 sets - 1x daily - 7x weekly Seated Single Arm Chest Press with Anchored Resistance - 10 reps - 2 sets - 1x daily - 7x weekly Standing Row with Resistance with Anchored Resistance at Chest Height Palms Down - 10 reps - 2 sets - 1x daily - 7x weekly
0,DC PT due to change in status.
0,Pt dc from PT is unexpected therefore status report for all goals not assessed.
1,"She did benefit from skilled PT Tx and she did demonstrate functional improvements, but she eventually reached a functional plateau."
0,"For both FOMS, compared to age matched norms, pt continues to be positive fall risk."
0,"She now has confidence to leave her home, negotiate stairs and curbs, and ambulate in the community."
0,"Pt has been seen by PT for extended period of time due to multiple hospitalizations, surgical procedures, and changes to overall functional status."
0,The patient does not adhere to safety recommendations due to impaired insight to fall risk.
0,Pt has reached max benefit from skilled PT intervention.
0,"The patient does c/o tailbone pain from a recent fall, but this is resolving independent of therapy services and does not appear to require services at this time."
0,The patient completes HAP independently and will attend ALF exercise classes upon discharge.
1,"At this time, the patient has achieved his optimal rehab potential and is appropriate for discharge with a thorough HEP/HAP."
1,He will do well to continue for improved quality of life and overall wellness.
1,"Patient is currently demonstrating improved bilateral lower extremities strength, standing balance, standing tolerance and overall activity tolerance, improved safety technique with Independent transfers on/off variety of surfaces throughout facility, improved ambulation distance with safety of utilization of newly obtained rollator throughout facility Independently, on immediate outdoor surfaces at facility with Supervision recommended for outings due to cognitive status."
0,No further skilled PT at this time.
1,"Currently, pt demonstrates improvement in core stability via achieved Dynamic Sitting Balance and improved score of Sitting Balance Test, and improved WBing through LEs during sit to stand attempts with and without standing frame support."
0,The patient will benefit from NRSG based home care services in order to manage medical status.
1,Tinetti balance assessment tool improved from 10/28 at IE to 17/28 at DC.
0,FOMs shows the pt is at risk of fall and goal was set for the maximum functional level.
0,Pt needs new R-prosthetic leg after seeing PCP.
0,Pt.
1,"Pt's B hip flexion and B knee flexion A/PROM has improved over time, which has helped to reduce pain level and improve gait quality."
0,"Her pain is the biggest limitation to further ambulation progress, but she is walking and transferring independently and no longer has limitations in ADLs due to shoulder pain."
0,Patient will be discharged at this time due to skilled care no longer being required.
0,This allows pt to maintain LE strength for transfers and mobility with family and staff within room.
0,"She has returned to ambulating farther distances in the community and is not concerned about relying on others for a ride to appointments, the store, etc."
0,Pt was also working on transitioning from the RW to a SPC.
0,had a significant decline in mobility over the past year and was not going in and out of the home secondary to difficulty with steps.
0,"He required moderate assist for supine<>sit transfers and sit<>stand transfers at IE, however is now independent with both of these activities."
0,Patient and family were explained they can resume therapy with a new referral after her rehab/ home services conclude.
0,Pain diminished and pt able to stand and walk throughout home for toileting and meals in bathroom and sitting area.
1,"Achieved increased BLE strength, improved sit to stand transfers, bed mobility, static and dynamic balance and gait using RW, ambulates to the dining for meals, however with escort for safety."
0,Chair Rise Test was also slightly slower.
1,"Pt able to benefit with improved transfer technique, and LE strength to maintain ability for transfers and pivoting for within facility."
0,"However, pt has become independent with HEP and will continue with exercises to continue to make further progress."
0,"Patient hospitalized 5/18/22 with a UTI and frequent falls, went to STR and then moved to an ALF (memory care) - Suffield by the River and active with home care services."
0,Unexpected discharge.
0,Son was in agreement.
0,At this point in time however patient didn't show any change with TUG and chair rise test but patient scored 9/10 on PSFS scale.
0,"at the time of  evaluation patient presented with impaired strength in BLE, impaired activity tolerance and endurance, difficulty performing bed mobility, difficulty in functional transfers, inability to ambulate."
1,"Pt has made significant progress overall since start of care, with most recent months focused on maintenance program to maintain pt's level of function and assist with slowing the progression of Parkinson's disease."
1,"Pt no longer requires skilled care as most goals have been met or partially met, and pt able to be discharged to HEP which were reviewed with CG, who is independent with written program."
0,Pt does not require continued skilled PT at this time as she has reached most of her goals and has plateaued in progress on her other goals.
0,The patient will benefit from PT services in order to ensure safety as the patient has had a decline in functional status.
0,"Therefore, an electric wheelchair is recommended for independent mobility in SLC."
0,"Pt status on dc report reflects pt status today during PT session, therefore missing update for many goals for most recent treatment."
0,Pt will be discharged today achieving and partially achieving all set goals by physical therapist.
0,Discharge today from fox rehab.
1,Client has met goals and is aware of discharge.
0,Pt currently is at her highest functional status.
0,Patient discharged without visit.
0,Patient is able to go out to the mail box and bring in the mails independently.
0,Wife still reports that he sits most of the day and is resistant to listening to her encouragement to do exercises.
1,"Has significantly improved her ROM and strength of bilat shoulders, despite chronicity of L shoulder ROM and strength deficits, has reduced her pain to <4/10 intensity at worst, and reports that her difficulties getting in/out of bed and transferring has resolved with skilled PT."
0,"Upon discharge, the patient ambulates up to 400ft with RW independently, performs sit to stand transfers independently, and negotiates steps with SBA."
0,Pt has provided and educated on HEP to prevent from further decline in function.
0,Patient no longer requires skilled physical therapy services.
0,"She is ambulating, transferring, negotiating steps and performing ADLs mostly independent and with occasional close supervision from caregivers as appropriate."
0,Pt is brought to activities daily by staff/ aides and attempts to actively participate.
0,She struggled with home compliance with HEP due to memory deficits as well as significant pain levels.
0,During treatment patient reached all goals with curb negotiation at Standby assist with family member for outings.
1,Pt has reached her max rehab potential.
0,Patient was seen for 6 visits under skilled maintenance (see recert for rehab goals DC'd at that time) and at this time is capable of carrying out exercises and HEP with caregivers.
0,Patient continues to tolerate PROM of RLE well with therapist.
0,Pt's O2 levels affecting him with higher intensity of interventions.
1,"Chair Rise Test goal has also been achieved to reflect inc BLE strength and STS efficiency, though MMT scores are unchanged since most recent PR."
0,"Per pt report, she will remain at YNHH for 2-3 days with plans to be discharged to SNF for short term rehab for approx 7 days."
0,To discharge at this time.
0,Client to benefit from continued use of hoyer lift.
0,Pt.
1,Transfer: Pt is able to transfer from sitting position to standing with SET UP assist which was MOD assist from chair with improved tech.Patient showed improved tolerance from dining room chair durnignIE.
0,"Pt has increased independence in functional transfers, household and community ambulation s AD on even and uneven surfaces."
0,Pt is a 75 year old who presented to PT s/p COVID-19 resulting in general deconditioning and low endurance on 2L O2.
1,Pt has achieved PT goals
1,"Pt's standing balance has improved as suggested by inc Berg Balance Scale score, with pt reporting feeling more confident with standing unsupported and with reaching (esp standing in kitchen to organize medications)."
0,Pt will continue with daily home ex program.
0,Pt and son educated on monitoring progress over the next month and contacting PT for reconnect call in order to gauge further need for services in the future.
0,Pt able to increase ambulation distance to increase LE strength for transfers and transitions.
0,Patient hospitalized following Angiogram d/t calcified arteries.
0,"While still scoring as a fall risk, client was receptive to transitioning to a rollator within the home and community to compensate for balance deficits."
0,He continues tostruggle w/ endurance and continues to demonstrate gait abnormalities due to wide BOS and impaired posture.
0,Medical insurance changed as of 3/1/22 and son forgot to notify FOX for PT services.
1,Pt has partially achieved PT goals as pt has plateaued in is abilities at this time
0,"Caregiver previously unaware that MedA and MedB services unable to overlap, did not inform therapist of RN evaluation previously."
0,"HEP 100% carry over, left shoulder still with pain."
0,"Pt was progressing steadily towards goals of increasing LE strength, endurance, pain management, and improving balance."
1,Pt appropriate for DC due to plateau with PT.
0,"Was recommended for discharge to subacute rehab, but family declined at this time."
0,"Her blood pressure has stabilized, no longer requiring skilled monitoring and modification during sessions and is she is appropriate for discharge from PT services at this time."
0,Tried to contact the patient was no response and Cert has already expired.
0,"Patient has been seen for skilled physical therapy treatment as prescribed by primary care physician to address recent decline in functional mobility, increased level of assistance required for daily tasks, increased risk for falls s/p recent fall, poor safety awareness and technique due to changes in cognitive status."
1,"During the course of treatment patient was provided with exercises to improve strenght, transfers, balance and improve activity tolerance and endurance."
1,Pt had reached all rehab goals.
0,She continues to be limited due to shoulder and hand dysfunction and walking is always limited due to difficulty holding onto counter or walker with her UE's.
0,Patient was approaching discharge date when family requested to hold services until a more convenient time for the CG was available.
1,"She continues to lack minor AROM on the R, but her HEP will continue to improve upon deficits."
0,"Pt able to demonstrate increased LE strength by reduced time on 5x chair rise test, and improving overall quality of transfers."
1,"At this time, pt has partially achieved or achieved most goals and has reached max rehab potential - recommend d/c to HEP and active participation in ALFs activities - pt in agreement and in full understanding that needs to continue with activities daily."
0,Pt is able to operate her device safely and she may be independent with the use of her electric wheelchair at SLC to increase independence and socialization.
1,"Patient being discharged this date due to achieving highest maximum potential with skilled PT services resulting in improved B LE strength, balance, and overall functional mobility and decrease in pain."
1,"In addition, she has also demonstrated improvement in her PSFS score."
1,Improvement in FOMs: PSFS from 4/10 to 9/10 and 30 second sit to stand from 1 to 8.
0,Client's cognitive and behavioral status hinder her ability to actively participate.
0,Pt was discharged from hospital to rehabilitation 3 days ago.
0,provided with HEP.
1,her walking has improved and she is able to walk slower with good balance.
0,patient is still in acute hospital and plan to have medical A services.
0,Educated caregivers and RN staff at SLC on indicators to refer back to PT in the future.
0,"At this time, patient has received his optimal function and is being discharged."
1,Patient has made good progress towards the goal and has achieved the strength and balance goal - able to stand with feet apart and together x30 seconds.
0,"Pt's FOM, strength in LEs and functional endurance and ability to participate in advance balance therex also demonstrate decreased aforementioned impairments and falls risk."
1,"Reviewed exercises with patient and educated her on proper form, dosage, and frequency for all exercises to be done independently for continued functional gains beyond the date of discharge, for patient to keep up her mobility and overall to promote healthy aging."
0,Pt and caregiver are now indpendent with HEP and will be discharged to HEP to continue to work on LE strength and balance and decrease fall risk.
0,Unexpected D/C.
0,Clinician entering unexpected early FMLA.
0,Education will persist with patient and family to start in person PT/OT for functional activites and SLP for cognition.
0,Client unwilling to trial ambulation with FWW and requests minimal participation in PT sessions.
0,The patient is not appropriate for PT at this time
1,Patient has made excellent progress towards the goals and has met all the goals.
0,Thank you.
1,Patient declined further services at this time with goals partially achieved.
0,"Completed initial evaluation of patient but then was not able to work with her again, due to pt having COVID and being admitted to the hospital for approximately 1 week."
1,Pt has made significant progress with PT to date.
0,POA was notified.
0,Patient will be reassessed as physician advises.
0,Patient plans to transition to private pay services.
0,"Skilled PT has been focused on restoring ROM and strength in bilateral LE in order to support body weight in standing and gait as well as preparing pt for possible R TKR, which is currently on hold due to global pandemic."
0,provided with home activity program to continue with caregiver for balance training.
1,"He demonstrates improved R shoulder ROM in all planes, improved strength, and decreased pain overall."
1,Pt to be DC from skilled PT POC secondary to reaching max functional gains.
0,"His transfers and self care are all safe and functional, he no longer requires skilled therapy."
0,Encouraged pt to continue to attend Daily Stretch at the ALF as well as walk during the day to maintain her strength following DC.
0,Pt continues to demonstrate limited carryover per session related to cognitive impairment 2' Dementia.
0,"Pt, girlfriend, and daughter aware of reconnect call."
1,Patient has reached his maximum potential at this time and no longer requires continued PT services.
0,He will benefit from PT when medical status stabilizes.
1,Pt reported over the phone to therapist that she is confident in her current balance/functional status (demonstrating improved subjective report of function in addition to improved PSFS).
0,HEP manual provided and demonstrated c HHA verbalizes understanding on safe performance and safety c HEP.
0,"Upon evaluation, pt has decreased BLE strength and static and dynamic standing balance compared to men of his age group, as noted in 30 sec STS and 2MWT."
1,"Improvements on this report reflect ""baseline"" as only status on progress report last week, but progress throughout POC from IE to DC includes: LE strength improved from 3-/5 all major ms groups at IE  (hip, knee, ankle) to 4/5 at DC."
1,"Patient has made significant improvement in gait pattern, gait speed, endurance, confidence, strength, balance, and overall is a decreased fall risk."
1,"He was found on floor in bedroom at night, disoriented, with significant altered mental status that did not improve."
1,"Patient has made little progress in functional mobility since IE, so patient is likely approaching highest functional potential at this time and is appropriate for discharge."
1,Pt has met all of his set goals.
1,"Since IE, pt has been able to make some improvements in LE strength and power, balance and CV endurance."
1,She still has pain but has improved body awareness and pain management strategies.
0,Patient is more confident and doesnt fear of falling.
1,"Pt has been able to achieve all goals related to balance, and strength."
0,"Pt no longer requires skilled physical therapy, recommend DC for now."
1,"As a result of cognitive impairment, patient has not achieved all goals, however CG and family are able to provide appropriate cueing to ensure optimal safety with bed mobility, transfers, and ambulation."
0,Pt has also been steadily increasing core activation to allow for bed mobility and bilateral rolling to improving changing for caregivers.
0,Patient unable to follow POC/Unable keep appointments more than 1 time per week.POA cancels multiple appointments for no apparent reason and shows poor consistence=y following POC.
1,Patient to be discharged at this time as he has optimized gains made in PT at this time.
0,Pt needs to care for other health and personal problems before she will be able to focus on therapy.
0,Client has been attending family functions and community outings with friends with increased balance and safety.
1,"He has shown improvements in LE strength, knowledge of how to correct his gait deviations w/ cueing, and improved transfer assistance."
0,She is now able to perform all daily activites without limitation and is independent with HEP.
0,Patient has had repeated cancellations and cancelled 3 recent appointment.
0,The patient was admitted for outpatient.
0,Pt was notified that she will be discharged from FOX services at this time and pt reports understanding.
0,"John Bartels Jr, 87 yrs old male was referred to skilled PT due to recent onset functional decline."
0,"This has contributed to independence with all functional mobility: sit<>supine, sit<>stand transfers from all home surfaces, ambulation indoors and outdoors, and stair navigation with appropriate UE placement/grab bar use."
1,Pt has met most goals at this time and no longer requires skilled physical therapy.
0,She continues to have difficulty with balance and continues to get radicular symptoms.
0,patient nor daughter in law requested to hold therapy visit but has not called back.
0,Will be discharged from Fox services at this time.
0,Pt has provided and educated on HEP to prevent from further decline in function.
0,Pt.
0,request.
1,At this point in time patient has achieved his hight level of function.
0,Patient had high BP readings and was monitored throughout the therapy session and physician is aware of the changes in BP and is not of concern.
0,Pt's niece wanting to seek out possible physical therapy covered by her insurance instead of purchasing more private pay wellness visits.
0,Family endorses they will install a railing in the sunroom to maximize safety.
0,Pt discharging due to leaving the country in the coming weeks.
0,Pt.
1,His activity tolerance has improved from ambulating 200 feet to being able to ambulate on level and unlevel surfaces with rollator for up to 10 minutes and distances of at least 1200 feet without rest to increase his participation in community outings for MD appointments and socialization.
0,"Pt has declined in gait distance but increased to independent assist level with rollator walker in her apt, with pt preferring to amb in apt only to avoid use of portable O2 tanks."
1,"The patient has made good progress with gait, transfers, static and dynamic balance."
1,Patient has made good progress and has met most goals set by PT.
1,Pt achieved most of her goals and  has plateaued with great progress since eval.
1,Previously achieved goal for strength.
0,Patient is able to perform HEP independently.
0,"Pt is refereed for PT due to balance impairment and gate abnormality, and high risk of falling."
1,"Pt has progressed IND transfers w/ rollator, and IND ambulation w/ rollator, improvements in mobility due to improved hip strength and increased limits of stability."
0,"Pt needs SBA with sit to stand transfer and stand pivot transfer assist,  and set up with bed mobility, she can ambulate around the unit with stand by assist."
0,Pt continues to intermittently report various hip/knee pain with sudden straight-leg-raise movements and struggles w/ bodily coordination per his condition.
0,The patient requested to be discharged now per patient request.
0,Communication was maintained with his daughter during this certification period and she concurs with discharge at this time and will reorder PT in future if needed and will continue on present HEP .
0,He can get in and out of walk in shower himself but is choosing to remain with private pay option for assistance.
0,"has a history of OA, spinal stenosis and falls."
1,Pt was able to achieved PSFS goal and partially achieved the rest of the goal.
0,Patient has been instructed in HEP.
0,A new chair glide was installed in stairwells so client no longer needs to do stairs if elevator out.
1,"Patient was provided with Skilled PT to improve strength, balance, transfers and bed mobility training and gait training using RW."
1,"Pt was given extensive HEP program consisting of balance, strengthening, stretching, core and posture exercises and was educated on importance of compliance to maintain gains from skilled PT."
0,Equilibrium challenges and functional tasks performed with cues for safety and technique provided.
0,"Had goals of decreasing patient from 2 person to 1 person txf, however staff continue to use 2 persons for safety due to intermittent LOB."
0,Pt.
1,Pt has previously achieved all BLE goals and achieved independence with functional mobility and reached maximal potential with FOMs.
0,Pt will continue adhering in HEP c encouragement provided by caregiver and family members.
0,Patient was COVID positive for his last week of therapy and that's why a non visit discharge is occurring.
0,Pt to be discharged at this time.
0,CG will try to facilitate HEP.
1,Patient had continued to make gains with regards to balance and gait mobility with minimal back pain.
1,"Pt has been seen for skilled PT 2x/week since 3/31/22 with focus on LE and core strength, balance and activity tolerance to improve safe functional mobility in SLC."
0,"Pt was seen for w/c fitting for assist with postural stability, mobility safety and to reduce risk for skin breakdown."
1,BLE strength and Sitting balance has shown some improvements.
0,"Pt reports unable to do ""anything"" for past week, no ambulation, sitting, standing, or sidelying."
0,Patient was making slow progress due to fluctuation in his medical condition patient was not able to have the consistency with the treatment session and hence is discharged from therapy for now.
1,Only goals not achieved are curb negotiation as noted due to minA needed for safety ABC rating greatly improved as well but fell short in 80% confidence but note it is due to patient increased self awareness with safety with movement.
0,Pt and family purchased an electric WC and pt has progressed well with the training.
0,"Due to the above and primarily due to her compromised pulmonary system and chronic low back pain, pt cannot walk long distances with her rollator walker or independently use a manual wheelchair for long distances safely."
0,HEP was demonstrated and handout were provided to patient and CG to continue at home along with ambulation indoors and outdoors using rollator.
0,is now routinely exiting and entering her home with supervision of a caregiver.
0,Client presenting for discharge assessment on this date.
1,Pt has met all her initial goals.
0,the previous month and anticipate the need for further skilled care once the integrity of his skin his under control.
0,"Pt is being d/c at this time following admission to Moss Rehab for subacute therapy, now f/u c Moss Rehab outpatient to continue prosthetic training."
0,"Due to recent fall and objective change in patient status, he is inappropriate for continued care due to concerns for safety and is appropriate for discharge, at this time."
1,"Recommend pt continue prescribed HEP in order to maintain or improve LE strength, functional activity tolerance, dynamic balance, and hip ROM."
0,She has met goal to maintain chronic knee pain without increasing with mobility.
1,"Since IE, pt was initially making great gains in LE strength in balance, enabling her to continue with gait training t/o her home, however endured a fall in September resulting in onset of severe LBP and severe decline in function."
1,Pt has achieved PT goals & HEP were provided.
1,Unexpected discharge today with some goals partially met.
0,At this time pt has reached max fxnl capacity & is formally d/c from PT.
0,"Pt had not yet retested FOMs to demonsrtate any progress, and functional mobility not yet goal level."
0,"Mr. Chunko experiences chronic issues that he was unable to control but has responded well to skilled physical therapy intervention and has become more increasingly aware of his limitations and ability to control his levels of stiffness and, ultimately, his pain experience."
0,"Although he experiences chronic psoriatic wounds on each of his distal BLE, this was exacerbated due to having to have necrotic tissue surgically removed from the base of his LLE big toe, limiting his ability to weight bear."
1,Patient has achieved most goals throughout course of care.
0,Reviewed doctor's referral which stated they needed skilled nursing care and social work referral.
0,"He is independent in transfers on and off toilet, armchairs and bed."
0,"At the time of evaluation patient presented with generalised weakness, poor endurance, static and dynamic balance impairments,impairments in transfers and ambulation."
0,Clinician opting to discharge at this time.
0,client and caregiver aware of discharge today.
0,They discovered at the hospital that she had massive internal bleeding and would most likely not make it much longer since they cannot operate at her age.
0,Pt is a 77 year old male who has been on service since 2/15/22.
0,Pt was able to increase core control for transfers and sitting balance.
0,"PCP has changed his depression medication, but he is not yet feeling any impacts."
1,She also demonstrates improved gait speed and ability to ambulate further distances.
0,Pt is now able to walk to/from the bathroom and is using the bedside commode less often.
0,"Patient continues to fluctuate so increased assistance required depending on energy levels, which family is able to adjust to."
0,Pt was suffering from a bronchial infection and is going to stop therapy for now.
0,P transitioned to hospice 2 days after initial evaluation
1,Pt has reached her max independence in functional transfers c min A to SBA needed d/t safety concerns despite improved technique and sequencing in the activity.
1,"During the course of therapy session patient was provided with exercises to improve strength, static and dynamic balance, gait training."
0,Patient no longer requires skilled physical therapy services.
1,"Pt's LE strength and STS efficiency has improved as indicated by Chair Rise Test score, and pt feels more confident with STS transfers from w/c, bed, and recliner."
1,Recommend pt continue to remain active at home and adult day center to maintain functional gains.
1,Strength BIL LE improved to 4/5 hip strength.
1,"Patient was referred to PT due to significant decline in functional indep and recent falls, with PT POC, patient has significantly improved balance, ability to walk with SPC as needed (not limited in distance with inc CVS), negotiate stairs/curbs, improved functional strength and CVS, perform transfers from all surfaces used in home and indep with HEP/DC POC."
0,Pt refused to continue PT intervention stating that taking care of her husband is already a full time job and doing more makes her exhausted.
0,Pt is not willing to participate in progressive strength / balance program at this time as she is "too tired".
1,"Previously, the patient was transitioned in to maintenance care to due achieving his baseline with the need to limit regression due to his experience with a progressive neurological disease."
0,He is still in hospital and will be discharging home in next few days with 24/7 caregivers and home health services.
0,Patient will continue to require SBA for safety with her transfers and ambulation.
1,At this point Patient has likely achieved her highest level of functioning safely.
1,Pt has been able to increase LE strength and meet age related standard on 5x chair rise test to improve safety with transfers and reduce fall risk.
1,Pt able to make good progressions toward goals.
0,Was hospitalized and also found to be Covid-19 positive.
1,She achieved and partially achieved all FOMs and reports a greater quality of life.
0,Pt has demonstrated progress since SOC.
1,"Patient has been able to consistently progress NM control, balance reaction, and stability interventions throughout the course of skilled PT to improve dynamic stability within apartment as pt frequently mobilizes without walker in short distances that affected pt safety to pivot and turn."
0,Pt's caregiver reports that day following initial evaluation for skilled physical therapy intervention pt suffered a massive stroke and was hospitalized.
0,Pt has been having several changes due to progression of dementia.
1,"Since starting physical therapy Beverly has shown improvements in LBP (rarely c/o limitations), L knee pain (w/ fluctuation per activity), strength, gait, balance, and improved in all FOMs."
1,Pt needs to adjust for leg length discrepancy with insert or built up shoe in order to improve ability to walk and decrease back pain.
0,"DC evaluation with patient achieving the following: 1.increase strength on Hip flexion, knee extension with decrease CV endurance 2. minimal increase strength on L shoulder flexors, abductors  3.fluctuating size L arm edema 4.Independent as to ambulation  6.significant decrease of Pain on low back during prolonged sitting, standing and walking( 3/5) 7. significant increase of core muscles with increase ROM  on B hamstrings and piriformis muscle Patient has reached her max functional limit and was given HEP to prevent future decline"
1,"Patient has made good progress in BLE strength and static and dynamic balance as well, also made good improvements in functional sit<>Stand transfers and gait."
0,"At the SOC her TUG was 36secs, and then progressed to 32secs, then 23secs, then 20.5secs, then 23secs, then 25secs, and she d/ced at 23secs."
0,Pt is to be discharged at this point as he has progressed enough towards his goals that he can continue independently on his endurance and strength training to further meet his goals.
0,"Pt's PSFS score reflects inc confidence in general mobility and exercise participation, and pt and spouse have demonstrated consistent carryover of HEP components including LSVT BIG techniques (UE reach, LE steps, etc.)"
1,"Achieved increased LE strength, bed mobility, sit to stand transfers, balance and gait, however cont to demo increased anxiety and been losing weight."
0,looses balance and instable when feet together.
0,A referral has been submitted for OT services to address home safety and PD progression.
0,Pt presented difficult with consistency of visits due to irritability which significantly affected treatment sessions as she would not want to tolerate interventions.
1,"Pt made gradual progress over course of PT POC, with fluctuations t/o d/t progression of dementia."
1,On time of evaluation pt required MOD assist and at the time of discharge pt is able to ambulate SBA using RW inside house over 40feet.Due to progression in PD and severe valgus deformity patient will require SBA and hence discontinue goal for independent ambulating.
0,Client to be discharged d/t frequent refusals and unwillingness to participate.
0,Educated to call back and reach to clinician if needing any questions.
0,No further skilled PT needed at this time
1,"Posture: moderate sacral tilt, posterior pelvic tilt, thoracic kyphosis, rounded shoulder and forward head slightly improved to minimal observation at DC however only w/ 25% carryover of postural correction and only when cued (not spontaneous) dt faulty habitual posture and impaired cognition."
0,Has not been able to perform exercises due to pain.
0,"Pt seen in skilled PT 1-3x/week with a focus on improving LE strength, knee ROM, transfer technique, gait mechanics, standing balance, and gait speed."
0,"She feels he is doing what he can do and won't get better, she does not want to possibly increase pain/fatigue."
0,The patient no longer requires skilled PT intervention at this time.
0,Educated pt that she will be discharged from PT at this time - encouraged her to continue completing seated HEP and walking program daily and that she can return to therapy services in the future when she is willing and able to participate in progressive strength/balance training.
0,At this time duahgter and patient would like to focus on her medical issues and discharge PT at this time.
1,"Pt able to make slight improvements of mobility by reducing assistance required with ambulation, and consistently increase ambulation distance."
1,Pt is appropriate for discharge at this time given safe functioning in her ALF and likely achievement of max functional level.
0,RD was informed
0,HEP manual provided and demonstrated with HHA verbalizes understanding on safe performance and safety with HEP.
1,Patient has achieved most goals of plan of care and is now at a low risk of falling based on functional outcome measures.
0,Pt is discharged from PT at this time.
0,Patient transitioned to HHA due to cellulitis on R lower leg
0,She is being unexpectedly being discharged.
0,Unexpected discharge.
1,Increased strength in BLE as it indicates in MMT and improved static standing balance and stability.
0,Pt to continue with HEP and routine follow ups with PCP.
0,Pt admitted to St. Joseph's Manor Rehab on 5/24.
0,Pt had to cancel last visit due to MD appointment and family visitors.
0,"At this time, patient's DIL is requesting to hold off on further PT sessions, as she wants the patient seen later in the day per CG request."
0,"At this time, patient is no longer an appropriate candidate for skilled PT services."
0,"Patient has maintained at CLOF and is safe to discharge to wife with adherence to HEP, attending Arcadia University Stay fit program for PD in order to remaining living in his home with wife with decrease burden."
0,PT provided some strategies that pt can try but pt insist that she did not want PT for now.
0,Pt will be discharged to HEP
0,Patient is a resident of Chelsea ALF who was referred to PT services due to recurrent falls and difficulty with gait.
1,Patient had done well with skilled services in a limited frequency due to his daughter's concerns withlimited allowed visits on his present insurance plan.
0,Over the last 1-2 weeks pt's status has declined.
1,Patient ha made good progress and has met 5/8 goals.
0,Patient showed poor compliance and tolerance to therapy.
1,"At this time, patient is being discharged from PT services due to reaching maximum therapy potential."
1,Pt demo good progress towards all goals since initial PT eval.
0,"She displays good safety with set up, transfers, and maneuvering in and out of apartment, on and off of elevator, in halls and in common areas."
0,Skilled PT isn't indicated and pt is discharged Redirecting required during tx secondary to pt with periodic outbursts .
1,"Pt is in agreement with PT DC and notes improved function in daily activities, including improved confidence with standing frame transfers for upright tolerance and calf strengthening."
0,"Recently, there has been noted decline in his functional status between sessions with decrease ability to ambulate or complete transfers without the need for assistance."
0,"Patient declined to participate in balance, and FOM s."
1,Pt exhibits improvements in B/L strength - therefore is indep with all ADLs and transfers.
0,"Additional skilled PT interventions were required due to complexities in d/x including Pneumothorax, Osteoarthritis, and HTN."
0,Spoke with patient's wife to follow up with patient's care.
0,Pt has met meaningful goals to her including walking dog with I and has an HEP and balance training program to assist with further progress.
0,"At this time, patient no longer requires skilled PT services."
0,Pt is appropriate for D/C from PT at this time and has been advised to discuss further PT with MD in 2-3 months if warranted d/t any decline.
1,Pt has made great progress since SOC.
0,displayed independence with all exercises.
0,only goes out in community with friends/family so aware that they should assist with taking the rollator in and out of home/car.
0,Pt is still not discharged from hospital at this time.
0,"The patient currently requires max A for bed mobility and repositioning in WC, and total A with use of Hoyer lift for transfers between bed and WC, which her HHA is able to provide."
0,Client to return to facility at unknown time and will be transitioned to home health agency.
1,"Pt has had improved strength, endurance, ability to transfer, negotiate steps, ambulate short distances without an AD and longer distances with a RW."
0,Pt will be discharged from skilled PT at this time.
0,Patient level of assistance varies from mod to max assistance due to fluctuation in her cognitive levels.
0,Neighbor called to cancel appt today stating the patient had some blood in her stool yesterday and then today when her aide arrived she called 911 since Jeanette was not looking well.
1,"Although patient did not completely achieve the goals, patient made great improvement in his PSFS score, scoring 7.0/10."
0,shows good carryover with using rollator in home compared to not using AD at all in home.
0,The patient's R hip pain has largely resolved and has been compliant with HEP.
0,"Written/pictorial instructions have been provided for these exercises, and others, to assist with pt's compliance."
0,Patient requested to be discharged from services stating "I just don't have any energy to have therapy right now".
0,Patient and caregiver were provided with HEP to continue to prevent functional decline.
0,Patient ambulates 250-300 feet outdoors with rollator require SBA at discharge and RW indoors 75 feet with SBA vs at evaluation he amb with standard walker require min assist and VCs.
0,"pt has (I) HEP, pt and caregivers educated in safe transfers from all surfaces and pt aware of safe distances to ambulate with rwalker without increasing pain in hip and groin."
1,He has improved back pain from 7/10 to 4/10 with activity.
0,Client to participate in memory care unit's exercise class and walking group to maintain CLOF.
0,Pt requires to be discharged due to having wound on LE.
1,"At this time, patient is independent with HEP."
0,He requires is modified independent in mobility in most areas with AD.
0,"Caregiver staff at facility provided with training on proper cueing, level of assistance with mobility, reminders on utilization of rollator at all times, attendance of group exercise reminders and encouragement."
0,"Pt was referred for skilled PT/OT services from Fox, but is not appropriate to receive PT services at this time."
0,Instructed patient and primary caregivers in increased opportunities for functional task.
1,"Over the course of skilled physical therapy plan of care, pt has made excellent gains in progress, meeting many goals over the weeks of therapy sessions."
0,Clinician contacted this client to discuss options of either seeing covering therapist for scheduled discharge or having this clinician complete discharge document without formal assessment.
0,Clinician remains in close contact with this family and will reconnect with client and / or family upon return from FMLA.
1,"Pt has made significant progress with physical therapy and has reached all of her goals demonstrating improved strength, balance and overall function."
0,"Patient continues to be followed by PCP for urinary incontinence/urgency, T2DM with integumentary/somatosensory/visual complications as well as multiple specialists including but not limited to pain management for fluctuating low back pain being managed by injections, cardiology for CHF.Patient was adherent to HEP over plan of care, educated patient on importance of continuing with prescribed HEP to maintain strength, balance, aerobic capacity and overall independence/quality of life."
0,He is currently able to perform several full flights of steps.
0,The patient was referred to PT following a progression of PD.
0,Plan to follow up with pt in future and obtain new script if needed from vendor and/or physician for future face to face visit.
0,has reach her max functional capacity and is at plateaued stage of recovery.
1,Pt is doing well with her mobility.
0,No further skilled need at this time.
0,"She reports that he will not need further therapy and that he has been brought a hospital bed, w/c and shower seat and that he is going to be getting regular aide visits."
0,The patient no longer requires skilled PT intervention at this time.
0,Pt.
0,"Pt's LE strength, balance and gait were WNL."
0,she has participated in 28 PT sessions.
0,Anthony is discharged to his HEP at this time.
1,"Pt was able to achieve goals on transfer, gait, PSFS and chair rise test, and was able to partially achieve bed mobility and TUG."
0,Pt is now using W/C for primary mobiltiy.
0,Patient had significant decline around Thanksgiving.
1,Patient and caregiver have been given HEP to continue to facilitate endurance gains and maintain functional mobility.
0,DC as pt still at hospital and ALF plans for pt to have homecare services when she returns to ALF after hospitalization.
0,HEP and activity was given to continue exercises to prevent future decline.
0,"Unable to receive services from both Masonicare and Fox Rehab, resulting in discharge."
1,"Goals were adjusted to best reflect pt's potential due to severe decline, however pt able to achieve Min A with all functional tasks."
0,Wife Sally reports there is no further need for skilled PT and they are still trying to decide if she should move him out of the house or not.
0,OT referral submitted today to address ADL and UE strength impairments.
1,Patient has been able to achieve and/or partially achieve all of her therapy goals.
0,"Eileen has had an extended course of care, complicated many times throughout by pain issues and muscle cramping, change in caregivers, and ultimately a change in environment, leaving her home in the community and moving to an assisted living facility."
0,Transfer training initially by stand pivot and later patient was not able to stand.
0,Several goals were not measured due to the abrupt nature of his discharge.
1,Pt will continue to work to maintain the achieved physical level with the prescribed HEP.
0,Pt performs TE with assistance and varying level of participation.
0,"Pt was provided with written/pictorial instructions for HEP to include STS, standing hip ABD, standing hip ext, standing hip flexion, mini squat, and side stepping at counter, and pt/CG were educated re: importance of regular HEP compliance after D/C."
1,Pt will benefit from cont participation w/ HEP to maintain strength & fxnl gains to prevent future decline.
1,"She has demonstrated improvements in her quality of ambulation with use of her cane, although does have some inconsistencies in performance depending on pain levels and feelings of stiffness."
1,"Pt have reached its maximum potential.. Pt needs assist of one  with sit to stand transfer and stand pivot transfer, pt is non ambulatory due to impaired standing balance secondary to pain."
1,"Pt has reached all rehab goals, has increased strength in BLE as it indicates in MMT, has improved static standing balance and stability."
0,"Received phone call from patient this AM, requesting to cancel today's appointment and discontinue therapy at this time."
1,"Pts wall to occiput measurement consistent today, however has improved since eval indicating improved posture."
0,patient admitted in rehab following hospitalization Patient showed varying level of tolerance to exercise however patient was admitted in hospital over the weekend
1,pt no longer requires skilled PT- she is (I) in all mobility and has an daily schedule established with a written calendar- staff has been educated to assist pt in following daily plan
0,"Anthony's POC has been slowed, in part from anxiety limiting his ability and participation in transitioning to the EOB for progressive strengthening."
1,"Patient refused to ambulate outdoors during the therapy session due to fear of falling, hence PSFS was partially achieved."
1,transfers: improved from minA w/ PA to mod A at times from low surface at IE to currently setup.
0,with left shoulder arthropathy now seen in OT services to address this impairment.
0,Pt was hospitalized following which she is admitted to rehab facility
0,Patient was placed on a hold from 3/18/2020 to 5/07/2020 due to COVID19 and rising cases in NYC.
0,Richard 81yr old referred to skilled PT due to recent onset of functional declined after hospitalization.
1,Patient has achieved highest practical level of function with skilled PT intervention at this time.
1,Patient plateaued with physical progress since eval and is now appropriate for discharge.
0,"Client, spouse, and POA in agreement with discharge on this date."
0,Pt has required significant education for compliance with his HEP due to poor carryover and multiple PT stents in the he past two years due to poor compliance.
0,training was provided using sliding board to transfers from bed to wheelchair.
1,Pt has achieved PT goals
1,Eileen has made substansial gains since beginning PT.
0,The patient no longer requires skilled PT intervention at this time.
0,Pt does not perform HEP even the exercises she can perform on her own without CG assist
0,HEP provided to continue exercises and prevent future decline
0,He has had a final HEP procured and demonstrates adequate understanding of how to perform safely.
0,"Provided education on benefits of exercise, recommended participation in SLC activities to increase mobility within his day, and provided education on steps to return to therapy when he is ""motivated"" to pt, his daughter, and RNs at SLC."
0,Patient seen for an additional session today as requested by patient's daughter/POA for additional session of training for safe utilization of custom wheelchair for daughter and private caregiver.
1,"Pt's standing balance is improved as suggested by inc Berg Balance Scale score, which is her highest score to date."
0,His last fall occurred when attempting to ambulation without AD resulting in a head laceration.
0,Pt no longer requires skilled PT at this time.
1,Patient hasachieved most goals throughout course of care.
0,would consider resuming PT if patient walking more.
0,"Pt has reached a plateau in progress and is appropriate for D/C from PT at this time, with plan to transition to private pay PT services."
0,Pt contacted therapist via text message informing this writer that she is currently at Chestnut Knolls for rehabilitation.
1,"She demonstrates improved ability to ambulate longer distances, increased LE strength, decreased R hip/knee pain, and improved balance."
0,"Pt has been seen for skilled PT services for ~15 months after R CVA in June 2020 causing L hemiplegia and resulting deficits in functional mobility, ADLs and daily activities."
1,"Patient has achieved maximum rehab potential The patient has dementia and bilateral shoulder dysfunction left RCT, right limited AROM which contribute to carryover of training and restricted reaching"
0,"Despite multiple medical issues the patient was able to progress from the rollator walker to a SPC for short distances, uses the rollator walker for community distances."
1,The patient has reached maximum rehab potential and is safe for discharge
0,"Due to his history of non-compliance with HEP following prior encounters of physical therapy, private pay wellness services were offered however pt declined  services due to out of pocket expense."
1,"Due to cognitive impairment, difficult to engage patient in therapy sessions weekly, resulting in inability to achieve all goals."
0,Pt's left knee arthritis causing discomfort & stiffness & current therapy not benefiting patient at this time
0,She is now able to go out for longer walks in her neighborhood and on community errands with husband or CG using upright walker with supervision.
1,"He was total assist for ambulation with RW at IE, however now is independent with use of RW and quad cane on level and unlevel surfaces, which has improved his ability to attend doctors appts, Penn State football games and family events."
0,"Pt transitioned to skilled nursing for Foley catheter and Therapy services, will be d/c for now and will restart Therapy after HHA discharged."
0,"Pt had difficulty maintaining progress, and presented with increased assistance with transfers over the last 2-3 treatment sessions."
0,Pt is dc from PT at this time for SNF admission.
0,Patient seen for skilled PT three times per week with taper to one time per week since 2/14/22.
0,Presented to therapy due to difficulty transferring and completing mobility with staff.
0,Client remains on skilled OT services as of now and will follow - up with treating OT this week.
0,She currently manages with changes in position and activity.
0,"She is stronger on stairs, not needing assist on higher step and is performing them more quickly than she used to."
0,Pt not adherent to POC and requesting for female PT.
0,Pt no longer requires skilled services and is able to complete HEP and walking program with cues from his spouse to facilitate initiation.
1,"Pt demo improved CV stamina with all activities with no SOB, esp with standing activities, however with proper pacing and rest periods."
0,"patient, wife and daughter present today."
1,"At this time, pt has trialed a R knee brace w/ varying improvement."
0,She will benefit from contineud HEP performance and follow up as needed.
0,Pt has been able complete ambulating transfers into bed with staff to maintain strength.
0,Pt.
1,Pt is appropriate for dc and will continue HEP.
0,Ralph's daughter disclosed that Ralph had passed away on Monday.
0,"Pt is I with rollator walker in apartment, requiring frequent and prolonged seated rest breaks."
1,She is now independent with HEP and will continue with HEP to further improve R knee pain and activity tolerance.
0,due to pts cognitive status he has been self limiting in participating in skilled therapy- his aides have been educated in having pt ambulate with walker and avoiding shuffling gait
1,Pt being DC on this day due to reaching max rehab potential at this time.
1,An HEP has been created to assist with gains made.
0,Pt still in hospital and certification period has ended.
1,PFS score improved from 2.0/10 at evaluation to 8/10 at discharge.
0,"Patient is indpendent with supine<>sit, set up assistance/MI with transfers, set up assistance for at least 100 feet with Rollator, set up assistance for 2 flights of stairs with SPC and unilateral railing."
0,Patient states she is able to stand in line to take communion in church which she was not able to do before.
0,Provided training to the caregiver on bed mobility and transfers from bed to wheelchair.
1,Patient has made excellent progress since start of care.
0,Patient regressed significantly without skilled therapy and appears to be more forgetful as she no longer remembers to do her HEP.
0,Pt has demonstrated progress since SOC.
1,This has improved patients posture and walking abilities.
0,Pt has 24 hour CG and their daughter is a PT.
0,Patient's husband encouraged to increase activity of pt by joining facility programs and activities and to increase pt's socialization.
0,PT had previously modified PoC as pt was demonstrating functional decline due to impaired safety awareness which resulted in falls.
0,Pt has been demo progress towards goals since initial PT eval but requested to discontinue skilled PT as she does not feel she is improving and is satisfied with her current level of function.
0,Four stage balance test unable to be assessed at DC due to pt politely requesting to stop session.
1,Patient met goals for PT POC.
0,Patient has reached plateau in progress and is demonstrating poor carryover of attempted HEP with CG.
0,"Pt and CG demonstrated 100% return of technique of most recent HEP including mini squats, heel raises, and knee lifting, 3 sets X 10 reps, daily, and will require no further training on these exercises."
0,DC as pt no longer requires skilled PT.
1,"Most notable gains include improvements in BLE strength, gait quality, amb endurance dynamic balance, and confidence."
0,"As a result of PT services, pt has increased B LE strength, functional mobility, increased independence with transfers using elevated recliner, and ability to safely enter/exit home and car."
0,Patient ambulating as needed to bathroom kitchen and around apartment with RW.
0,Patient made a tremendous progress in strength balance gait.
0,Pt required education for HAP and HEP and she was competent with both at time of evaluation.
0,Daughter was notified and had good understanding of plan for DC.
1,client has made slow and steady progress towards goals and caregiver is now independent in HEP and HAP.
1,pt was making excellent progress in all areas and no longer had nighttime private duty aide
0,"Was provided home exercise program for continued balance training, was compliant with use throughout POC, and demonstrated ability to safely perform."
1,"Pt is Indep with transfers, ambulation and stair negotiation using SC."
1,Patient has achieved most of her goals and has now plateaued with great progress since evaluation.
0,"Pt spouse reports worsening LE weakness, stating he may require rehab."
1,She has improved from maxA for STS Transfers to completing 10 STSs in 30 seconds.
0,The patient has declined greater than 3 attempts for PT sessions.
1,"Patient had a hospital admission to North Shore University Hospital on 8/19/2020 due to low hemoglobin levels, anemia, Lewy Body Dementia, acute UTI and excessive BLE swelling potentially due to CHF."
0,Pt and pt's family agree with discharge plans.
0,"Pt requested to be dc, per pt "" I feel I'm not getting better"""
0,Pt was admitted at the hospital
0,Pt has been referred to OT and was evaluated this week to assist with ADL safety and managing progression of dementia.
1,Client presenting for discharge on this date d/t achievement of maximal level of functional potential at this time.
0,"Additionally, patient scored 11 transfers on the 30 second sit to stand test, in which the goal was 12 transfers."
0,"Pt was evaluated d/t request from CG d/t pt's decline in mobility levels and sedentary status resulting in difficulties w/ transfers, ambulation and posture."
1,"Pt made gradual progress over course of care, with fluctuations noted in all areas d/t progression of Parkinson's disease."
0,Patient has requested to be discharged at this time.
1,Excellent progress noted since initial evaluation.
0,"She remains at total assist, max assist for all care and would require either mechanical lift or assist of 2 caregivers for mobility for safety reasons."
0,"Pt reports that upon return from North Carolina, she went to Baystate Hospital and was dx w compression fractures in lower spine."
1,"Patient i,proved UE strength improved form overall score of 3/5 to 3+/5."
0,"Pt has been educated on HEP, proper body mechanics, and balance reactions t/o all activities and demonstrated appropriate knowledge and safety w/ all movement patterns."
0,"Throughout PT POC, pt and CG trained in LE flexibility and strengthening HEP, and trained in safe use of standing frame."
0,Discharge PT.
0,"Lois Locke is a 80 y/o female referred to PT for a decline in functional mobility, transfers and strength in the presence of advanced dementia."
1,Pt able to ambulate 400 ft uisng rollator Indep.
1,"Her performance on FOMs is inconsistent, but functionally pt has improved and she has only had 1 fall at ALF, which was while trying to shower without assistance, which was her misunderstanding of the assistance she was supposed to receive."
1,"Over this episode of care, pt has improved in all of these areas."
0,Pt has been hospitalized and DC to short term rehabilitation.
0,Due to cognitive deficits patient was not able to progress as planned in the POC.
0,"Spoke with OT, who is going to continue under maintenance."
0,Pt has also been educated re: energy conservation considerations d/t MG diagnosis and need to find balance between activity and rest.
1,"Has increased strength and muscular endurance in BLE as it indicates in MMT and 5x STS, has improved balance and stability during functional mobility at home and community."
0,However the PSFS scores 7.3/10.
0,Pt son/POA made aware of DC and in agreement with recommendations.
0,Nurse advised wife she could not have services w/Fox and nursing care from them.
0,Unable to assess due to not being able to see patient.
0,Therapist speaks to patient's wife.
1,"Since most recent PN on 10/16, TUG score has improved by 3.5 sec and 30 sec STS result improved by 1 trial."
0,"Limitations throughout POC included L knee pain, lower back pain, several falls throughout POC and fluctuating status associated with symptoms related to PD."
0,"Patient has difficulty with sit to stand transfers, ambulation requiring +2 to 3 TA with the use of rolling walker."
1,She exceeded her PFSF goal score indicating significant improvement with functional mobility and a decrease in hospitalization risk.
1,"Demonstrated good results on balance testing, gait, transfer performance."
1,"patient has achieved multiple goals throughout POC, including improved strength across extremities and trunk, sitting balance and transfers, and he partially achieved his PSFS but due to discontinuing stand goal this was not achieved."
0,To have geripsych consult and referred to OT for possible intervention.
1,Pt and her caregivers have been educated on HEP to maintain gains and pt is ready for discharge from skilled PT at this time.
1,Over all his PSFS has improved and he now demonstrates a lesser burden of care to his spouse and daily caregivers.
1,"As a result of skilled PT services, patient has demonstrated improvements with balance, B LE strength, functional mobility, and standing tolerance."
1,Pt's mobility has improved overall so that she can walk the long distances required in the ALF to get to dining and activities rooms.
0,"Transfers STS coming from bed, couch and chair Independent."
1,Pt has been been able to increase b knee extension AROM to 0 degrees to improve standing ability and quad strength.
0,Richard Calabro is a 78 y/o male referred to FOX Rehab for gait and balance training in the presence of Alzheimer's Disease.
0,Goals not met.
0,Pt able to demonstrate increased gait speed allowing for increasedstrength and endurance.
0,"On evaluation Pt was found to have the above mentioned impairment along with impaired transfer ability, upper and lower extremity weakness."
1,"Patient is demonstrating improved BLE strength, safe and Independent transfers on/off variety of surfaces throughout facility and outdoors, safe and Independent ambulation throughout facility and on outdoor surfaces with patient initiated rest prior to onset of fatigue."
1,"Pt was able to achieve goal with transfers and stair negotiation and partially achieved goals on gait, pain, TUG, 30 seconds STS and PSFS."
0,Pt is to go to PCP regarding decreased energy levels however educated likely due to decreased caloric intake and water intake that is contributing.
0,Patient transitioned to HHA due to wound care.
1,Client has shown an improvement in balance as indicated by 19 point increase in his BBS.
1,Pt demonstrates ongoing improvement in balance and strength as demonstrated by achieving most of his goals and improving on all of them.
1,"Since starting PT, patient's strength has been restored, his static and dynamic balance has improved (see outcome measures), he requires decreased assistance for ambulation, and he is now independent with transfers (sit to stands, bed mobility)."
1,Patient is independent with her home activity program and demonstrates excellent ability to maintain CLOF and independent mobility throughout SLC.
0,Pt is kept in one position for majority of the day in manual W/C without any special cushions to offload her bottom.
1,Patient was able to achieve goals set at time of eval.
0,She reports more confidence in her walking and her balance.
1,"Pt has been able to consistently walk in her home with w/c follow, with improved foot clearance and safety with turning; she has been educated re: importance of daily walking with her daughter assisting with w/c follow for safety, in order to address endurance and maintain ability to walk short distances."
1,Patient when was able to improved upper and lower extremity strength.
1,Pt achieved IND bed mobility in previous progress report.
0,Pt has had various co-morbidities and hindrances t/o POC but is now ready for discharge and is independent with HEP.
0,She has been educated in HEP and HAP and demonstrates ability to perform.
0,"Patient is discharged from services at this time due to son/POA testing positive for COVID-19, followed by patient testing positive and symptomatic."
1,"Due to services, patient has demonstrated improvements in B LE strength, balance, and overall functional mobility."
0,She is more unsteady with cane and RW is still recommended to prevent fall risk.
1,"Pt discharged today as Pt achieved indep with using walker and SPC when walking to dining area for meals with vertigo symptoms resolved with vestibular rehab and also Pt provided with education on safety when walking, HEP for exercises to maintain therapy gains and also for Pt to participate with SLC group exercises and continue with walking program to maintain functional mobility."
1,Pt has reached max rehab potential however increased independence and adherence to HEP c wife's encouragement and reminder.
0,Pt.
0,"Today pt declined performing exercises or functional mobility today to reassess final ability, however last observation of skills pt not at goal level."
0,The patient no longer appropriate for skilled PT intervention due to noncompliance with program.
0,"Due to poor carry over in between sessions and lack of supervision, pt still remains fall risk and should have 24 hour supervision."
0,"as well as standing 3- way hip, hamstring stretching, SLR, scapular retraction, and lumbar flexion stretches."
0,Patient has tolerated PT treatment well and without major incident.
0,As a result will DC PT.
0,"Pt is appropriate for discharge, however, due to progress made over course of care and reaching a plateau in PT progress."
0,"Pt has been seen for ~1 year of skilled PT services to address low back and LE pain, decreased strength, imbalance, postural deficits, decreased endurance and impaired functional mobility secondary to vertebral compression fracture."
0,Focus of therapy has been on improving functional balance and LE strength.
0,"Pt, staff and daughter are aware and agree with discharge plan."
0,She has been educated in optimal positioning and PLB to manage SOB and facilitate breathing.
1,Patient has been able to make significant progress with skilled PT.
0,Pt sent to ER and returned home this am with new diagnosis of pneumonia and returned to ER today as pt with low O2 sats and increased RR noted during PT session.
0,Patient has been seen in PT for generalized weakness and impaired balance after hospitilization for COVID-19.
0,Patient reached most goals with ambulation distance goals not reached due to patient displaying signs of fatigue and encouraged to initiate rest prior to onset of fatigue.
0,HEP written and diagrammed provided with patient training provided and patient demonstrating safe and Independent follow through.
0,She was first referred to Fox Rehab for PT Tx to address a functional decline s/p suffering from falls and s/p undergoing a L hip ORIF.
0,Patient requires wound care and is being transitioned to home health for nursing services.
0,"Recommend pt continue to perform HEP and ambulation within home with assistance from caregiver and/or wife in order to maintain LE strength, balance, mobility, and activity tolerance."
1,"At this time, pt has reached her max functional potential, indicating DC from skilled PT services."
0,"pt with new UTI, being seen by Stratford VNA to follow up with IV antibiotic treatment"
0,when needed.
0,Client requesting for this clinician to complete discharge without formal assessment performed.
0,Plan to transition pt to independent HEP at this time and d/c current case.
0,"Pt had also tested (+) For R sided BPPV, which was addressed with Dix Hallpike, and pt has since been able to differentiate since then that she experiences lightheadedness in response to tx activities, instead of dizziness."
0,He is able to use RW to ambulate to his car and can get in and out of car safely.
0,Pt also able to self proper in wheelchair and lock/unlock brakes properly .Pt is performing HEP independently at this time.
1,Patient has achieved most goals throughout POC and after transitioning to maintenance care.
1,Patient received 63 treatment sessions for skilled therapy to improve safe (I) ambulation s/p AKA with prosthesis.
0,"Patient has been seen as referred by primary care physician to address recent decline in functional mobility, increased level of assistance required for daily tasks, increased risk for falls s/p recent fall."
1,Client has shown improved functional strength in LE's with improved consistency rising from standard surfaces on first attempt.
0,Pt seems to demonstrate adequate understanding of home exercise program and will continue to ambulate for exercise and maintenance of cardiovascular endurance.
0,"She has also been provided a HEP that has been reviewed and modified throughout the plan of care to assist pt with remaining physically active with daily walking, lower extremity strengthening exercises, and exercises to assist with general mobility of lower extremities and low back."
0,Daughter was educated that FOX only provides therapies.
1,Pt is being discharged today with partial achievement of all goals
1,PSFS goal has been achieved to reflect overall improvement in mobility and exercise.
0,Weather conditions limited ability to ascend/descend a curb.
0,Patient and family educated on multiple times and shown to have poor compliance with therapy.
0,Pt's R shoulder and low back pain is bettermanaged with addition of postural exercises and stretching/ROM interventions to address flexibility and reduce stiffness.
0,Spouse has been involved w/ pt's progress and POC especially towards DC as COVID restrictions in facility eased and vaccination was completed for both parties  pt's spouse now visits regularly again to memory care unit (she lives in IL section) and is able to carryover HEP.
0,No further skilled PT required at this time
1,She demonstrates improved LE strength as shown by her improvements in her MMT and STS test.
0,Patient did not want PT follow up.
0,Patient will benefit from SBA for all functional transfers and gait with RW in facility and room.
0,"Primarily he has shown a reduction in low back pain that was limiting his sleep, walking, and bed mobility."
1,"pt no longer requires skilled PT due to having met goals but requires distant supervision during gait with rwalker- she is no longer using wheelchair as primary form of mobility, she ambulates with rollator around memory uni safely with decreased pain"
0,Patient is able to perform HEP with assistance from CG.
0,Client has made limited progress towards goals.
0,Meanwhile patient had a stroke over the weekend and was hospitalized.
1,"Pt has made excellent progress with skilled PT - she is now able to walk to/from dining room and activity room at SLC, get in/out of bed and transfer independently, and is able to return to community exercise class."
0,"Pt with multiple bouts of impaired CV response to tx activities throughout POC, demonstrating s/s consistent with exertional hypotension, and 1 instance of irregular pulse in response to orthostatic testing."
0,NP has requested D/C from Fox Rehab.
0,Unexpected discharge - client remains in inpatient rehab s/p fall with shoulder fracture.
0,New caregiver educated in set up and instructions to best assist pt with transfers.
0,"Recommend continued skilled PT services in order to progress strength, balance, and mobility."
0,"Upon discharge, the patient ambulates up to 600ft with RW independently, and performs sit to stand and stand pivot transfers independently."
0,"Pt and spouse were provided with education re: HEP (LTR, SLR, bridge, hamstring stretch, etc), vital sign monitoring, and cuing strategies to assist with PD management."
0,Pt dc from PT services due to request of ALF RN as plan for pt to have home care services when he returns from hospitalization.
0,"Patient was being seen by different therapist at beginning of POC, was only able to see one time before the fall which resulted in her being admitted to the SNF."
0,Patient will be reassessed as physician advises.
0,Patient's limiting factorcontinues to be her cognition with periods of decreased safety awareness during sequencing.
0,Spoke to nursing today and was informed that pt has been referred and is currently working with home health agency.
0,Progress had been slower due to hindering effects of hip surgery and healing process associated with such.
0,Limited progress made recently due to progression of PD and decline of functional mobility.
0,"The patient is I with transfers, I with ambulation with wheeled walker when he elects to use, otherwise he requires supervision."
0,PT and pt's wife demonstrated 100% carry over with HEP
1,Improved gait with Rollator walker from mod assist on level surfaces x50 feet to independent on level surfaces with Rollator walker greater or equal to 100 feet and SBA on unlevel surfaces greater or equal to 500 feet with Rollator walker.
1,"At this time, patient is independent with HEP and CG's are provided with proper safety strategies and cueing to decrease risk for future falls."
0,Pt's family currently attempting to utilize long term care services.
0,She is having much less LBP and knee pain although continues to be sore when she wakes up in the morning.
1,At this point of time patient has achieved her highest level of function and is discharged from therapy.
0,HEP manual provided and demonstrated with HHA verbalizes understanding on safe performance and safety with HEP.
0,Pt has a new CWC now and demo better sitting posture and more comfortable.
1,The pt has been provided with a HEP/HAP and he should continue to improve without the need for "skilled care".
0,This reduced his overall confidence and exacerbated his fear of falling and he primarily began using a WC as his primary means of mobility.
0,"Pt has cognitive impairments and lives with son, but does not get supervised or encouraged to stand and walk most of the day."
1,"Pt has made some gains, but progress is limited due to her limited participation in PT sessions."
1,"Pt demonstrates improved strength, ability to walk longer distances and ability to ascend and descend stairs safely."
1,Pt demonstrates good form and recall with exercises and is approp for discharge from PT at this time to continue making gains with HEP.
0,Pt has returned to PLOF during household and community amb and stair negotiation.
1,"She presents with much improved LE strength, power, safety awareness, transfers floor to stand and sit to stand and walking endurance."
0,No further skilled PT needed at this time.
0,Patient seen for skilled PT for BIL LE/core/UE theraputic exercise to progress toward goal of standing and walking.
0,"Pt able to reduce assistance required for transfers to only minimal physical assistance from recliner, and moderate from lower WC."
0,"Patient was referred to PT s/p fall, resulting in LBP."
0,Pt.
0,Pt seen for PT eval only and has declined PT visits since eval last week due to status of LLE s/p cat bite.
1,Pt made good progress with physical therapy indicating improved balance and strength as demonstrated by tests and meeting most of his goals.
0,Patient is being discharged from PT services after passing away earlier this morning.
0,Patient discharged to home health episode due to wound on toe on left foot.
0,PT planned to address W/C mobility and further CG education for improving safety of ambulation with CG assist.
0,Spoke with pt on phone in the afternoon and she reports that she went to Wound Care Center and started homecare nursing services today.
0,Pt will be discharged at this time.
0,Patient discharged from skilled PT services at this time.
0,Pt experienced a fall when wearing slippery socks in her apt and picking up the phone.
0,Continued PT would not be skilled at this point.
0,She adds that she knows her HEP and will do her best to complete daily
0,Pt.
0,At this time pt has met max functional benefit with PT services and recommend she carryover HEP and HAP as she is able in regards to her respiratory status resting as needed to manage SOB.
0,"However pt became more sedentary, and difficulty sequencing stepping movements with ambulation."
1,Pt will continue to work to maintain the achieved physical level with the prescribed HEP.
0,Pt discharged to HEP to continue with strengthening program independently.
0,Pt requires skilled nursing and home aid at this time.
0,DC PT.
0,"Patient seen for skilled physical therapy services as prescribed by primary care physician to address recent decline in functional mobility, increased level of assistance required with all tasks, increased risk for falls and poor endurance s/p recent fall, limited mobility, increased fear of falling."
0,HEP manual provided and demonstrated with HHA verbalizes understanding on safe performance and safety with HEP.
1,Improved functional transfers independent and ambulation c AD c SBA for safety.
1,Patient has made good progress with static balance of 30 secs able to stand with feet apart and together with eyes closed.
1,She has improved generalized strength as noted by FOMs and MMT and her balance is WNL.
1,"Static/dynamic balance, endurance, balance confidence and gait speed has improved as evidenced by Berg balance scale, 4 stage balance test, fullerton advanced balance, 2 min step test, TUG and ABC balance scale."
0,Pt had to be hospitalized to yale psychiatric hospital for chronic mental health issues.
0,Pt and daughters are more confident in medication and edema management and have been educated re: need for more regular vital sign monitoring to assist with home safety.
1,Pt already given HEP to maintain therapy gains.
0,Her and her caregivers have been educated on indicators to return to therapy in the future and have verbalized understanding and agreement with plan to discharge today.
0,She will continue to perform core and LE strengthening on her own to continue to make progress with radicular pain.
0,Pt no longer requires skilled PT at this time.
1,Pt has made excellent improvements with skilled PT.
0,Mary 88 years old female referred to skilled PT due instability during walking and history of falls.
0,Pt able to require slightly reduced assistance for transfers as treatment progressed.
1,She has reached her 5xSTS score demonstrating improved BLE functional strength as she demonstrates ind transfers now and ind with amb with improved gait pattern.
0,Progress has slowed and pt and PT agree with discharge.
1,Pt demonstrates improved gait mechanics with decreased R toe drag and improved heel strike with less restrictive AD for short distances indoors.
1,"During DC evaluation, Patient achieved the following: Improve strength on B UEx and LEx to 4/5, minimal assist as to sit to stand transfers increasing chair lift, moderate assist using her rolling walker and guard belt with decrease speed in ambulation and turning."
0,"Pt is not using Alinker at this time, reports is having handyman cut the frame so the seat is lowered a few inches so pt can walk forward onto seat, edu on risks of alinker and edu that Rollator is safest and most appropriate assistive device, pt verbalizes understanding."
1,"Pt's TUG score improved, indicating improved balance reactions."
0,Pt is independent with step into garage and into kitchen from her bedroom area of the home.
0,Pt has been educated on recommendations but expressed they are not willing at this time.
0,Plan to get new referral for PT once discharged from Patient Care.
0,has been seen in physical therapy services since 1/26/22 at a decreased frequency per pt.
0,"The patient is an 80 year old female, resident in a senior living community at Assisted Living level for medications."
0,"PSFS indicated improving pain levels overall (from 0/10 to 3/10) prior to exacerbation, however at this time returned to pre-treatment level."
0,He has two flights to egress his bedroom and bathroom area to leave home.
0,She will do well to continue with HEP program with support from her Caregivers.
0,"Patient is discharged today with HEP provided, caregiver education provided."
0,She is walking through the house and going outside with supervsion.
1,Pt has achieved personal goals at this time and has reached a plateau in progress  pt no longer requires skilled PT intervention and is appropriate for D/C at this time.
1,"Pt's gait speed and safety with turning has significantly improved since last PR, with faster TUG score, despite no change in Dynamic Gait Index score; pt exhibits generally improved safety with negotiating obstacles during gait."
0,"Upon discharge, the patient ambulates up to 1000ft with no AD and SBA and intermittently completes home activity program as prescribed."
0,They also allow her to sit in W/C all day with infrequent position changes and have not gotten her the recommended cushions to offload her bottom.
0,"Education has been provided on fall prevention, home safety and need to continue daily exercise and walking program."
0,Pt also now independent with HEP.
0,Pt at this time not benefiting him.
0,Pt DC at this time due to inactivity and POC ending.
0,PT has contacted pts doctor office several times regarding the change in his symptoms.
1,Pt has made great progress since start of care.
1,He demonstrates improved balance and improved LE strength.
1,Pt has partially achieved PT goals & desires to be discharged at this point
1,"Pt's Chair Rise Test score has significantly improved overall, reflecting inc BLE strength and STS efficiency, though score is not improved since last PR."
0,"Pt still presents with Trendelenburg gait pattern affecting R LE stepping activation, which has been chronic for her."
0,Patient is being discharged at this time due to hospitalization for COVID-19 which will be followed by short term rehab facility stay per patient's daughter/POA.
1,Pt have reached its maximum potential.
0,DC physical therapy due to pt meeting her goals and she is now able to continue with her HEP on her own with assist of spouse as needed.
0,HEP was provided to prevent future decline
0,He is however performing his HEP daily.
1,"Pt has made gains w/ PT and has reached max functional potential, and pt is pleased with progress."
0,Pt requested discharge today after she received her first bill from the first few sessions.
0,PT focused on educating HEP with some exercises that was done.
0,"Patient will be discharged from PT POC, does not require PT management at this time."
0,"Pt is being DC from PT at request of pt daughter as pt is moving to her daughter's home on 6/1/22 therefore pt/caregiver education provided to pt and daughter in recommendation for ongoing RW use maintaining close placement to pt of RW at all times, and assisting pt to amb with RW daily for safety, mobility and pain management."
1,has met goals for Chair rise test with a significant improvement with alternative method and able to complete without UEs demonstrating a significant improvement in functional LE strength.
1,Pt has made great progress since start of care he is now indpendent with ambulation with a rollator and SBA with cane during stairs and short ambulation distances.
0,Reports that she has been working with trainer at ALF and does not require return of therapist.
1,"Increased strength in R ankle/foot as it indicates in MMT, improved reactive standing balance on different surfaces."
1,"patient has made good progress over POC, achieving goals in pain management, strength, gait, and FOMs chair rise test and PSFS, indicating improve functional strength and endurance, as well as self efficacy."
0,Patient seen for skilled PT d/t decline in functional mobility and increased SOB with all activity.
0,Pt has refused PT x 4.
0,Pt also demonstrates low risk for falls per objective measures: Berg balance scale and chair rise test.
0,Pt does not want to sit in brand new tilt-in space W/C as she states it is uncomfortable on her legs and she can't maneuver herself.
0,Goals were not fully met due to chronic pain on knees and declining cognitive condition.
0,At this point in time patient has reached her highest level of function.
0,DC PT due to change in status with medicare A services.
0,Pt discharged at this time due to not having effective treatment sessions.
0,He verbalizes/demonstrates understanding to plan.
1,Achieved goal in reduction of R shoulder and arm pain from PS 7/10 to 2/10 improved standing posture via Wall-Occiput Measure from 25 to 21 cm decreased dependence in sit to/from stand transfers and stair ambulation from moderate to minimal assist decreased dependence in sit to/from supine transfers from maximal to minimal| assist decreased dependence in rolling to moderate to SBA achieved indep in assuming sidelying from minimal assist achieved indep in HEP from minimal assist and improved functions and decreased risks of hospitalization via PSFS from 4.7/10 to 5.3/10
0,Client's wife requested dc.
1,"Anthony's POC has focused on supine core strengthening and LE strengthening in an effort to improve his ability to participate in bed mobility, improve his ability to scoot and shift in bed for reduced pressure to posterior surfaces, and promote improved participation with all functional mobility."
0,Pt has been educated on need to see his doctor regarding his symptoms but refuses.
0,Patient is able to complete 100% competency HEP for B LEs utilizing written copy and states that she attends all exercise programs provided by ALF.
0,The patient has no more authorization.
0,"Client has been educated to use rollator at all times, keep pathways clear and perform HEP."
1,"Pt able to ambulate 350 ft uisng rollator community ambulation SUP, transfers and stair negotiation Indep."
0,The patient is a 98 year old female resident within a memory care unit with a 24 hour private caregiver.
0,Pt instructed in HEP and edu to attend Tu/Th FOX exercise class.
0,"Following initial evaluation, this PT was informed patient is receiving home care services for a wound through Masonicare."
0,Patient and his wife were provided with HEP to continue to prevent decline in function and to optimize the available functional abilities.
0,"Due to extensive muscle tone issues, cognition and safety issues, pt has maintained his mobility, is able to walk with maximum assistance from a male CG."
1,"During the course of treatment patient was provided with exercises to improve strength, balance and gait and stair training."
0,will be continuing an exercise program provided through the VA.
1,Pt has been able to increase static and dynamic stability allowing for improved pivoting within kitchen and bathroom for improved safety.
0,"Patient has been seen for skilled physical therapy services as prescribed by primary care physician to address recent decline in functional mobility s/p illness, limited mobility due to quarantine at ALF with exacerbation of OA symptoms in BLEs."
0,Patient has no pain on low back with better balance in independent ambulation and transfers.
0,PT is recommending patient ambulate with supervision to and from all meals with RW and gait belt to promote increased physical activity and carryover of increased independence with functional mobility and prevent functional decline post PT D/C.
0,Family would like to continue services but educated on insurance requirements and skilled need.
1,pt was making slow progress in all areas including transfers and minimal active mobility RLE and improved posture with cues.
0,He has been instructed in a home exercise program to maintain strength and ROM.
0,"Patient is now able to resume outings with family, attendance of many activities throughout facility and meals."
0,and pt's daughter are in agreement with discharge of services at this time.
0,"Attempted to educate patient about the role/purpose of PT to assist her recovery process and resume functional ability and safety to PLOF, however patient repeatedly refused to participate in PT visits due to fatigue."
1,"Pt has reached all rehab goals, has returned to PLOF."
0,Patient PSFS is 5.3/10.
1,The pt is being d/ced today d/t meeting max medical improvement with skilled PT Tx at this point in time.
0,"This was preceded by a significant fall in community bathroom that resulted in moderate discomfort, soreness, and increased fear of falling."
1,Safety awareness has improved as she is more safely setting up her walker to avoid having to reach out for it and is staying inside her walker when turning and transferring.
1,Patients strength has improved to 4+/5.
0,"Thorough education provided to CGs t/o her POC on functional mobility, pain mgmt and HEP with fair carryover."
0,Pt would benefitfrom resuming skilled PT upon hospital DC.
0,Pt is being discharged at this time as he has reached max benefit with physical therapy at this time.
0,Unable to formally assess goals.
1,Pt has made great progress since SOC.
0,Pt provided HEP and edu on CG and SLC assistance due to reported ability to downside and desire to be more indp and need for resources.
0,Pt's PCP has been notified of impaired vital signs response by both nursing staff at Mt.
0,has multiple medical co-morbidities limiting independence.
1,"Patient was provided with therapeutic exercises to improve strength in extremities, trunk mobility exercises, bed mobility transfer training."
0,Pt is independent with HEP but continues to have LE weakness which causes transfering from height of standard chair difficult.
1,Patient is being discharged with goals met.
0,Pt is now DC to continue HEP w/ caregiver assistance.
0,"At this time, clinician opting to discharge at this time d/t lack of progress and no further need for skilled care attempts."
0,Pt has been able to progress well to increasing LE strength and mobility within facility.
1,Patient has achieved most of her goals and has now plateaued with great progress since evals.
0,Pt will be transitioning to private pay wellness at this time to continue with physical therapy.
1,"Since SOC, pt has made significant progress in gait distance, LE strength and balance with improved Tinetti score."
1,"Improvements noted in dynamic balance (FGA, TUG) and well as static balance (mCTSIB)."
0,Patient has been referred to for visit nurse servcies d/t new pressure wound and PB management.
0,Client and clinician remain in close contact and clinician to follow - up with this client upon return from FMLA.
1,"She reports she is coming home soon, but on comfort measures only since she is not doing well at all."
0,Pt also required frequent monitoring of O2 for possible adjustment of supplemental O2 as needed during ther ex and activities.
1,"Pt demo improved BLE ms strength indicated by achieving FTSTS, improved balance indicated by improved TUG and BERG, improved CV stamina indicated by improved 6MWT and ambulation distance and improved functional independence indicated by decreased cues/assist during ambulation and achieving PSFS goal."
0,Patient continues to demonstrate decreased endurance (dyspnea on exertion) and requires SBA for ambulation secondary to cognitive status.
1,Tinetti score has improved from 14/28 to 17/28 and B LE strenght has improved specifically at hips.
0,Pt reported that she has been and will continue to complete HEP.
0,Patient's family and the PCP decided to stop the PT service.
0,Instructed patient and primary caregivers in increased opportunities for functional task.
1,Formal tests not completed as pt discontinued visits prior to reassessment but pt made gains in ability to ambulate with single point cane indoors and outdoors.
0,Patient was discharged from Uconn Hospital to Cherry Brook skilled nursing facility for short term rehab.
1,"She has made excellent progress with skilled PT - reduced her pain intensity, improved ROM, and demonstrates improved UE strength."
0,no call back from Pt.
0,Clinician and client to remain in close contact and will reinitiate services upon clinician's return if requested by client.
0,Caregivers have been instructed in cuing required for safety during activities and in simple program.
1,Plan to discharge at this time and follow up for potential needs after returning home.
1,patient has met goals and is agreeable to discharge.
0,"Pt is min a with ambulation using 2WW with left platform, Indepen with spt and sts."
0,"Due to late stage Alzheimer's Disease, patient has made slow progress with skilled PT services."
0,"Spoke with son and recommended that pt be evaluated by her PCP due to increased knee pain, decline in status and increased adverse behaviors with caregiver."
0,Pt may be referred to outpatient PT when pt completed HHE.
1,Pt has completed 33 PT sessions since SOC and has shown great progress as pt has met most PT goals and is indep with SPC and rollator walker use.
0,Patient's POA was informed of current level of function and recommendations and verbalized understanding.
0,"Patient is now able to walk to 3 meals a day independently with her rollator, and has not used her WC in over a month."
0,Not making much progress with telehealth due to no caregiver to assist with activities which pose a safety risk.
1,Patient's functional abilities have progressed as a result of skilled interventions and patient has reached maximum potential with skilled services.
0,He is independent with his HEP(strengthening and Walking program) to maintain his current level of mobility and prevent decline.
1,Patient was provided with skilled PT to improve the above mentioned impairments.
0,Patient is slow paced and requires increased time to complete the activity but able to complete the activity without assistance.
1,"Improved bed mobility and transfers, however cont to require x2 ModA and MinA  or x1 Max A and requires constant cues for proper tech and constant redirection to complete act."
1,pt has plateaued at current level of mobility- she has been limited in her progress during transfers and gait due to her fear of falling- caregivers have been educated in assisting pt during transfers and gait
0,He appears to over estimate his abilities.
1,"During DC evaluation, Patient has achieved the following: 1.increase strength on R Hip flexion, R knee extension, R ankle DF 2.still has weakness on R shoulder flexion/abduction, R elbow flexion/extension 3.independent in sit to stand transfer activity   4."
1,"The score improved from 60 to 30 sec at the time of discharge.Patient specific sore was compared, the result shows considerable improvement from 4.3 to 9 out of 10.TUG score was evaluated at the time of discharge and shown to have considerable improvement in balance with the score improved to 20 which was 37 at the time of initial eval.On the basis of clinical judgment and functional outcome measure the patient  has achieved the maximum functional level and reached platue."
0,"During the PT intervention cycle, pt was affected by chronic UTI's and varying levels of hemoglobin."
0,HEP manual provided and demonstrated with HHA verbalizes understanding on safe performance and safety with HEP.
0,"Pt is not using Alinker at this time, reports is having handyman cut the frame so the seat is lowered a few inches so pt can walk forward onto seat, edu on risks of alinker and edu that Rollator is safest and most appropriate assistive device, pt verbalizes understanding."
0,Pt was dc to the hospital
1,"PT is no longer medically needed, with patient achieving all set functional goals as noted and indep with HEP/DC POC."
0,"Was hospitalized for UTI for 1-2 weeks, discharged home for several days, and then returned to hospital."
0,However pt unable to make progressions with ambulation over the last few weeks.
1,Pain score improved from 2 and 7 to 0 and 2 at rest and activity respectively.Hence partilly achieved the goal.
1,"Pts 5TSTS score improved indicating improved LE strength and balance, goal not met due to pt utilized armrests for test."
0,"Patient had many fluctuations throughout POC 2/2 PD and outside personal factors (ie: spouses illness, passing away) impacting patient's physical abilities and causing increased fluctuations."
0,Patient was provided with HEP which he is uanble and unwilling to follow while agreeing to attend daily group exercises.
1,Upper and Lower extremity strength score improved from IE UE  score improved to 4+/5 at shoulder which was 3+/5 during IE Lower extremity strength improved BL strength improved from 3/5 to 4/5.
1,"Although patient did not fully achieve the goal established for gait, patient can now safely ambulate outdoors using a RW and SBA/supervision to resume community outings."
1,Pt has made great progress since start of care and is no longer having any back pain or radicular LE pain.
0,No further skilled services are required.
0,Pt has become independent with ambulation and transfers.
0,Patient recertified 4-5-2022 due to emerging diagnosis of neuromuscular involvement.
0,Pt hospitalized with UTI then sent to Meadow Ridge for continued skilled PT.
1,Pt would benefit from resuming skilled PT upon reduction of pain exacerbation to further reduce pain with improve functional mobility and strength.
1,Pt POC was partially achieved due to unexpected discharged upon patient's request.
1,STS transfer goal of Mod A has been achieved on 10/16 and CG has been educated on assistive techniques in STS and demonstrated 100% return of technique.
1,Patient has been making consistent gains toward short term and long term goals with current POC and will benefit from continued PT services in order to reduce negative effects of hospitalization and prolonged bedrest.
0,"Pt's gait capacity increased overall, and more focus was placed on pt's ability to dual task during gait as well as negotiate obstacles safely d/t motor planning impairment secondary to PD."
0,He will be starting outpatient PT at the Tully center for further physical rehabilitation.
1,Pt's transfers and ambulation have improved allowing her to get her mail and walk to hair salon in facility without difficulty.
0,Thank you.
0,At this time pt has reached max fxnl capacity & is formally d/c from PT.
0,Patient discharged unexpectedly due to patient death.
0,"Pt had very poor balance and postural control at IE, however now demonstrates good static and dynamic balance, which has increased his balance confidence by increase in ABC scale from 63% to 78%."
0,Patient D/C from services.
1,"At this time, pt has partially achieved most goals and recommend d/c to HEP and cont of Activities - pt in agreement and in full understanding that needs to continue with activities daily."
0,"Patient and Patient's family are in agreement.Formal DC assessment not completed as the FOMs are no longer appropriate, patient would not be able to tolerate testing.Discussed with Holli Smith APRN"
0,Informal DC performed.
0,She will continue to do well with her HEP on her own and OT referral submitted for hand therapy due to arthritis/hand pain.
0,Due to declining cognitive condition and low motivation pt is unable to completely understand the reason for continuous exercises and was unable to fully comply to POC.
1,He was given updated HEP at d/c and pt and wife were educated on importance of compliance to maintain gains from skilled PT.
0,"At the SOC her gait was 145ft then progressed to 191ft, then 488ft, then 676ft, then 269ft, then 407ft, and she d/ced at 274ft."
0,Pt to be discharged at this time.
1,Pt have reached its maximum potential.
0,Pt will continue c prescribed HEP.
1,"during the course of treatment patient was provided with skilled PT to improve strength in LE, static and dynamic balance training,safe transfers training and gait training."
0,However increased fatigue this week resulting in unexpected discharge and unable to assess FOMs.
0,Clinician offering to allow client to see covering clinician for discharge assessment or for this clinician to complete the discharge.
1,Pt has met all PT goals.
0,Pt is going to STR when she isdischarged.
1,"Pt is Indep with transfers, ambulation using SC and SUP with stair negotiation using BHR."
0,Spouse is confident that he will be able to continue through independent exercises.
0,No significant change in mobility with skilled PT.
0,Pt is being discharged this date and will continue with an ambulation (4x60 feet or as tolerated w WW and WC follow ) and biking program with EP at SLC to maintain LE strength and ROM needed for mobility.
0,Will reassess for PT services as clinically indicated.
1,Patient is being discharged as he is transitioning to Med A services with "Shamrock" and his wife hopes to continue PT with them as she feels he immediately improved cognitively and physically when beginning PT.
0,"At this time, patient does not require skilled PT services."
1,Pt has made great progress since SOC.
1,Pt at max potential and maintaining ability to doe short distance ambulation in the room for toileting.Just awaiting personalized w/c and paperwork in progress.
0,"She was with increased fatigue levels on most recent session, despite normal blood sugar levels in session, contributing to impaired performance on FOM testing."
0,Pt fell yesterday and broke her hip.
0,Pt still enrolled in Med A services DC indicated immediately.
0,Will discharge patient as he is now on Med A services.
0,The patient has been able to maintain his functional level with HEP provided with assistance of wife and paid aide.
0,Educated to reach out if feeling changes in status or unsteadiness.
0,Clients notified of private pay options and given main office number.
0,Pt negotiates 20 steps to egress home with SBA and using spc at discharge while at evaluation he was unable to perform steps at all.
0,"She reached TUG, Tinetti, and PSFS goals."
1,"Trialed addressing pt's posture mid-POC to promote improved CV endurance with minimal effectiveness noted, despite achievement of posture goal."
0,Pt has very little assist from CG and together they do not follow recommendations.
1,"Pt has progressed IND transfers w/ rollator, and IND ambulation w/ rollator, improvements in mobility due to improved hip strength and increased limits of stability."
0,Pt able to safely and comfortable perform multiple trials of 3 steps during treatment sessions.
0,"At this time, pt is recommended for DC from PT due to transition of services to VNA as per MD referral."
0,He continues to have a part time HHA and is independent in HEP.
0,"Patient is safe to discharge to HEP and daily walking program with wife with modifications for sitting and standing (based on symptom presentation on that day) and monitoring vitals in which CG demonstrates independence with monitoring vitals (BP, SpO2, and HR)."
0,Patient has made limited progress toward goals as a result of poor carryover.
1,Pt is currently in her max potential and will continue with HEP with assistance from CG.
0,Pt's discharge was originally planned for next week but clinician is needing to go on maternity leave sooner than anticipated.
0,"Client to participate, as tolerated, in daily exercise program hosted by facility and will ambulate throughout memory care unit with staff supervision."
0,"Therapist is unable to accommodate a later appointment at this time, so did explain to DIL that the patient will have to be placed back on the hold list until a therapist becomes available."
0,Patient encouraged to use Rollator walker at all times for mobility and UUE for functional reaching activities secondary to fluctuating activity tolerance and balance.
1,Patient specific score has improved to 9 which was 2.3 during IE.
0,Patient was provided with HEP to prevent falls and functional decline.
0,Patient and family agree with discharge and agree to continue with HEP and home activity program.
0,"Evaluation only as patient scored above age related normative values and is independent with bed mobility, transfers, and gait."
0,"Pt dc from PT services at request of SLC nurse, so that when pt returns from hospital homecare nursing services can be initiated."
0,Pt and PT agree with discharge at this time.
0,Received a call from patient's wife that Masonic care had initiated nursing services for monthly care of patient's Supra-Pubic tube.
1,Patient/caregivers have been educated on expectations on compliance with HEP print out following DC to avoid decline and continue to improve strength.
1,She has achieved low levels of pain and better pain management skills that help improve QOL.
1,Patient was provided with HEP to work towards long term goals.Patient was able to achieve the goal for upper and lower extremity strength with overall score of 4+/5 bilateral upper and lower extremity which was 3/5 during IE.
0,"Mr. Gallagher is an 86 year old male with a history of HTN, post-herpetic neuropathy, DM and partial quad tendon rupture @ L knee following TKR two years ago."
1,Plan to advance and progress with ongoing HEP at this time independently and will DC from further PT having met all established goals.
0,"Patricia 93 yrs old female referred for skilled PT due to recent onset of functional decline with history of HTN, muscle weakness in BLE, reduced static dynamic standing balances, difficulty with transfers and ambulation."
1,"Pt initiated physical therapy services with LE ROM and strength deficits, and core stability deficits, with pt goal to ambulate with rollator and improve upright standing tolerance in standing frame."
0,"Due to the inability to establish consistent and safe household mobility, this therapist recommends ALF placement."
0,Caregivers educated that someone needs to be with patient at all times in order to avoid falling.
1,Pt able to increase LE strength from 5x chair rise test improvement allowing for improved transition of transfers without needing use of UE.
1,"Pt overall made minimal progress due to having difficulty accepting treatment from clinician due to altered cognitive state, and being in emotional state."
1,Pt demonstrates improvement of gait up to Mod level of assistance due to improved BLE muscle strength and balance as a result of ther ex and activities prescribed in this POC.
1,Pt discharged with multiple goals met and some partially met.
0,Pt has reached goals.
1,His goals have been maximally achieved at home.
0,"Pt has been able to be independent with HEP to maintain endurance and LE strength at time of discharge, however difficult to keep up with ambulation as it requires assistance and son is only able to provide help 1x a week at most."
0,Barriers to achieving this goal were lack of second HR and size of steps for curved staircase.
1,However at this point in time patient has achieved her highest level of function.
0,"Not able to complete a D/C report in person due to COVID, still not allowing therapist into home."
1,Client was approaching discharge d/t achievement of maximal level of functional potential.
0,Pt.
0,Clinician contacted this client to discuss options of seeing covering therapist for formal discharge assessment (client has reached end of certification period and had scheduled discharge upcoming on Monday) or for this clinician to complete discharge document without formal assessment.
0,Pt D/C at this time 2* to achieving highest level of functional independence.
1,TUG score has demonstrated improvement however scores are inconsistent secondary to pt's level of anxiety.
0,DC indicated per request of pt's spouse to return OOP expenses for skilled private pay physical therapy.
0,At this time - no further skilled care is warranted.
0,Richard is discharged from PT at this time.
1,"However, pt's progress has plateaued at this time and it is likely that pt has achieved his maximum functional potential in skilled PT."
0,Pt has not been compliant with home activity or exercise program and CG does not reinforce increased activity.
1,"Pt strength has improved, per previously achieved 30s sit<>stand, contributing to sit<>stand transfers now independent."
1,"Pt's standing balance improved over time as indicated by inc Berg Balance Scale score, though score is unchanged since last PR."
0,Pt was given HEP to continue progressing independently at this time.
0,Pt declined PT services citing doing okay now
1,"Patient achieved the following: improved strength on B Lex, independent as to sit to stand transfers, Independent as to ambulation using rolling walker and SPC, improved balance as to ambulation and stair activity."
1,"Patient has made great progress in LLE strength and muscular endurance, and now is able to negotiate stairs independently."
0,Pt.
0,"To toilet only for BMs, not for urination at all at this time."
1,Pt to continue to increase mobility at home and stay active to maintain gains made with PT.
0,Patient will continue with HEP
0,Pt has had complications related to recent falls as well as ER visit due to severe back pain and diagnosed with sacroilitis.
1,"Pt required moderate support and stability at time of evaluation, and has been able to increase LE strength and NM control to allow for improved stability and reduced support when performing 3 stairs."
0,Patient given print out of home exercise program.
0,cushion on dining chair).
0,"Pt is heavily educated on importance of safety and reducing risk of falls including using rollator, not using cane at any points in the community or assisted living facility unless in the dining room with staff guarding, and energy conservation."
1,Pt had beendemonstrating significant gains in transfers and gait as outlined in recertification.
0,Patient requested dc today from PT as OT will begin and it is too difficult for him to have both services.
1,"Patient had been tolerating PT treatment well and making good progress towards functional goals, however she developed COVID-19 during episode of care."
1,"Pt demonstrating minimal gains with therapy services, unable to report MDC with FOMs resulting in ongoing fall risk with mobility tasks, complicated by poor safety awareness."
1,"Overall, the patient has made significant progress throughout his POC."
1,Patient has achieved most goals.
1,Client has demonstrated independence using deep breathing techniques to improve his activity tolerance for all activities.
0,"Throughout her POC, pt with brief instance of R hip pain that was able to resolve on it's own."
0,Pt was dc to the hospital for stent placement
1,Unable to report gains at this time due to declining medical status and short LOS.
1,Dynamic standing balance has improved and she has not had a fall in over a month.
0,At this time the CG and patient are both also IND with HEP as well as HEP progressions.
1,"Pt also demonstrate improved transfer abilities from MOD assist to independently transfer ability with improved technique and safely.Upper and lower extremity strength goal showed improvement and able to meet the goals.Upper and lower extremity overall strength improved from a score of 3+/5 to 4+/5.FOMs Patient specific sore was compared, the result shows considerable improvement from 3 to 10 out of 10.TUG test was evaluated at the time of discharge and shown to have considerable improvement in balance with the score improved to 38Sec which recorded 22sec at time of evaluation.The goal was discontinued due to slow transfer ability.Patient showed improvement in 5 times sit to stand from initial evaluation, the score improved from 56 sec to 34 sec and goal achieved.Patient is able to perform safe independent transfer however slow hence the goal is DC.On the basis of clinical judgment and functional outcome measure the patient  has achieved the maximum functional level."
0,PSFS score dec d/t pt's difficulty with progression of PD.
0,She is at prior level of function for all transfers and is not willing to participate in LE strengthening or gait training to reduce caregiver burden.
0,She still exhibits high anxiety and benefits from encouragement and distraction which her CGs are capable and knowledgeable in helping with.
0,Staff is independent in administering HEP with patient.
1,Has improved strength in BLE and activity tolerance.
1,Has shown improvements in strength in BLE as it indicates in MMT.
1,Minimal progress made during PT POC as only 2-3 treatment sessions were able to be completed before patient's wife was diagnosed with COVID and both pt and his wife had to stay quarantined/isolated in their room in AFL.
0,"Pt was progressing with skilled PT intervention however, she injured her arm and now is receiving nursing care."
0,"Estelle Abrams 85 yrs old female, referred to skilled PT due to recent onset of functional decline due to reduced physical activities and mobility."
1,She has plateaued in her progress and her husband is capable of helping pt maintain her gains through daily walks.
0,"Patient seen for 90+ days of skilled PT for training in bed mobility, transfers, gait, DME use, theraputic exercise, balance training, HEP and education."
1,Pt progressing towards goals steadily of increasing endurance and LE strength to improve function and safety when out in community.
0,No additional training is indicated at this time.
0,Pt is performing home ex program for balance and strengthening on daily basis.
1,"Patient has made good progress with strength , bed mobility and gait."
0,Pt was aware of high copay and was agreeable to once weekly appointments.
0,Patient no longer requires skilled PT intervention at this time.
0,"Pt declined, communication provided to son and daughter about patient stating that she does not want to continue."
1,"Throughout the POC pt has shown improved ambulator tolerance within the household, on stairs, and no longer continues to require skilled gait training."
0,Patient's daughter decided to stop the PT service and preserved the 13 remaining visits for future use.
0,Patient was given HEP for patient to continue after DC.
0,"Pt was referred to HHA due to recent fall, function decline and need for skilled nurse."
0,Pt able to increase duration of long sitting to alleviate back pain for when patient was going to be transitioning to power chair.
0,Will follow up in one month.
0,Patient is able to perform HEP independently.
0,He will do well to continue with independent HEP to maintain his progress and preserve his current functional abilities
0,Patient did not appear to have the motor control to work toward standing.
0,She will continue to do well walking with her aides and engaging in groupactivity and exercise activities
0,"Pt also newly has procured a caregiver for several hours a week to assist w/ cooking, cleaning, and household activity primarily due to difficulty w/ vision and legal blindness."
0,Pt unable to participate in PT services at this time.
0,Recommended OP services based on doctor's referral for mechanical traction and modalities for lumbar radiculopathy.
0,Pt able to maintain stability with EC on foam mat for up to 8 seconds without losing stability.
0,With significant increase of muscle strength on B knee muscles and B UEx except for hip flexors with the same muscle grade of 3+/5.
0,HEP was given for continuation of exercises.
0,"Patient is able to perform HEP with assistance from CG, who is properly trained to assist."
0,Today patient unexpectedly requested discharge from skilled therapy.
1,Pt not benefiting from current PT anymore as pt is resisting movements & gait training however pt is more verbal & bit more expressive in her current experiences of exercises & calling out to be left along in sitting
0,Pt will be discharged from skilled PT at this time.
1,Pt has progressed in all areas and has currently met goals for skilled services.
0,At this time patient no longer requires skilled PT intervention as CG s have been educated appropriately on HEP and current levels of assist for transfers and community ambulation.
0,"Pt is now independent with functional mobility, ambulate around the unit without any AD."
0,Patient no longer requires skilled services at this time.
1,"Pt make improvements in safety awareness and dynamic balance, resulting in improved gait, transfers, bed mobility, and stair safety with decr assistance needed."
0,When asked if she felt that she benefited from PT services: "Oh yes.
1,"During DC evaluation, Patient achieved the following: 1.Improve strength on B LEx and UEx 2.Independent with sit to stand transfer activity  3.Significant improvement as to balance with ambulation and transfers 5.Increase CV endurance especially with prolonged ambulation HAP was given to CG and daughter to be able to maintain progression and prevent further decline"
0,"Pt declined services after initial evaluation, and would prefer to only partake in OT services at this time."
0,They are also attending on site exercise programming at SLC 3-4x/wk.
0,Pt was experiencing a decline in function approx one month ago.
1,Patient progressing by increasing B ROM in knees improving about ~15 degrees since start of evaluation which was going to allow patient for improved comfort and safety when needing to sit in powered WC.
0,and educated on positioning the ipad to the right side so that patient is turned to the right and left side equally.
0,Patient to Caleb-Hitchcock tomorrow for STR.
0,"At this time, Anthony has self-limited progression to more functional EOB strengthening."
0,"Client received skilled therapy 3x/week then tapered to 2x/week receiving therapeutic exercise and activities for functional strengthening,  gait training on level surfaces and stairs to reduce risk of falls and fall related injuries, neuromuscular re-education for improving balance, and patient education for home modifications, disease management/deep breathing techniques, and HEP/HAP."
0,POA requesting that clinician complete discharge without formal assessment by covering clinician.
0,No skilled need for PT treatment at this time.
0,No further skilled PT needed at this time.
0,Stating that she needs some time to get her brace adjusted and for some time away from PT.
0,She has now changed her mind stating it will be too much to pay for.
0,"Her functional progress and her PT POC were both limited and complicated by her dementia, by her dec compliance with skilled care, by her pain, by a 1.5month gap in her POC d/t SLC covid 19 restrictions, and d/t her fatigue."
0,"resisting walking more and more, stretching and transfers can be performed by caregivers."
1,He did experience several falls as his confidence improved while trying higher level activities.
0,Recommended to performed standing balance once a day with the aid to prevent decline in functional status in transfer mobility.
0,"Was walking to closet at night without AD, experienced LOB and fell to chair, however landed on coccyx."
0,Family has still not put grab bars in bathroom doorway and do not supervise when she gets up to use restroom.
1,Pt requesting DC due to improved performance though has not fully achieved goals.
1,"Pt has made significant progress over the course of PT POC, with several medical management changes over this time period - IVIG, Soliris infusions, tapering down of prednisone dosage, cervical epidurals, etc."
1,Pt has achieved PT goals
0,He has had no falls since start of care.
1,Pt is being discharged from skilled PT at this time as pt has meet balance goals to improve proprioception/vestibular system to reduce risk of falls when navigating in the dark.
1,"HEP in place to maintain gains, pt understands role of continued exercises, understanding of reconnect call."
1,Patientmade good progress towards strength and balance and able to stand for 30 secs with eyes open and eyes closed with stability.
0,He has plateaued with therapy and has become independent with home exercises.
0,She stated her father needs palliative care with more disciplines involved at this time and needs to contact MD for referral to Med A company.
0,Non compliant to therapy
0,She verbalized understanding - RN staff at SLC educated as well on when to refer pt back for therapy services.
1,"Bed mobility: unable to perform supine<>sit at eval d/t fatigue; improved to setup w/ rail set up by OT previously, at DC."
0,Pt needs continued reinforcement to use cane at all times indoors and to use walker in middle of night or when fatigued due to instability.
1,Patient has improved transfers from max assist on eval to independent.
1,Pt has made significant progress with physical therapy and has not had any falls since starting therapy.
1,"Pts 5TSTS score improved indicating improved LE strength and balance, goal not met due to pt utilized armrests for test."
0,New problem of RT knee arthritis occurred during treatment and patient was treated with knee strengthening ex and Voltaren gel.
1,Patient shows improved safety and gait mechanics when it comes to using rollator.
1,She has met all goals except tandem balance but has made progress with balance and has met all LE strength goals.
0,Pt is being DC due to recent hospitalization and transition to SNF due to significant psychological changes.
0,"Expected to write recertification, however pt reports fall a week ago on Thursday."
0,"At the SOC her 5x STS test was 19secs, then progressed to 19secs, then 17secs, then 15secs,then 20secs, then 14secs, and she d/ced at 14secs."
0,"Patient has plateaued in skilled PT and is likely at baseline.Patient benefit from extended plan of care and likely to be appropriate for future physical therapy due to having cardiovascular, musculoskeletal, neurological and endocrine comorbidities with complications requiring modification of plan of care."
1,"Since starting physical therapy, pt has shown some improvements in R knee ROM, pain, gait distance and tolerance on uneven surfaces, transfers w/ less pain, SBA for stair negotiation w/ various cueing required while ascending."
0,The patient has been admitted by Home health services.
1,"Discharge was not planned, patient has an open wound ,hence patient trasnfered for Skilled nursing services  Ambulation: improvement from MOD assist  to SET UP assist with improved dynamic balance,however continue to show endurance deficit and valgus knee."
0,PT also provided CG education on safety and HEP recommendations to staff on multiple occasions with variable adherence.
0,Pt is now DC to continue HEP as tolerated.
0,At last visit pt ambulated outdoors 350-400 feet with a single point cane require min assist and with rollator require SBA even and uneven surfaces.
0,HEP program was provided to patient to continue after PT session.
0,Pt still has cognitive deficits that impair his compliance and carry over with any HEP.
0,Pt has increased cognitive limitations noted as confusion increases and safety is more compromised.
0,Patient refuses all PT services despite education on benefits.
0,Therapist unable to make contact with pt and family to schedule additional visits x3 weeks
0,"Therefore, pt and CG educated on HEP for maintenance."
0,Pt.
1,Pt has not made any significant progress due to low motivation and poor compliance with POC.
0,Pt participates in activities in home including daily walk with caregivers.
1,FOM 30sec sit to stand improved to 5 times which was recorded 1 at IE TUG test was performed and the patient was able to achieve higher score improved from 55sec to 34sec.Due to chronic pain and slowness while turning the goal modified to 30 sec.
1,Pt also demonstrate improved transfer abilities from MOD assist to SET UP assist transfer ability with improved technique and safely.Bilateral LE strength where evaluated and found to have achieved the goal set at the time of evaluation with an overall score of 4+/5 in bilateral LE.
0,"Education was a key part of his care for patient, daughter and HHA to facilitate carry over of HEP for flexibility and postural strength and overall balance."
1,"Pt has demonstrated improvement in both 30 second sit to stand and gait speed since evaluation, demonstrating improvement in LE strength and reduction in fall risk."
0,Pt is under VNA home health services
0,She has increased LE hip abd and knee extension strength.
0,Pt has a wound on his foot from callous removal and now will need nursing services under his medicare A benefits.
1,Achieved strength on B LEx with significant improvement of CV endurance.
1,"HEP taught to pt with 75-100% carry over, recommend to use Straight cane during ambulation to improve safety."
0,"Pt is now SBA in long distance ambulation throughout ALF and SBA in most transfers (pt occassionally requires up to min A when fatigued or when transferring from soft, low surfaces)."
1,"Achieved all balance goals, MCTSIB today and all others at previous measurements, indicating with both static and dynamic balance, and on uneven surfaces pt is at reduced fall risk at this time."
0,Pt has experienced many changes throughout POC.
0,Pt not feeling well & needs medical attention from neurologist.
0,Pt requesting DC due to previous falls resulting in months of increased pain and unable to perform functional mobility.
1,"FOMs: gait speed: comfortable gait speed improved from 0.22 m/s at IE to 0.75 m/s at DC, and fast gait speed improved from 0.24 m/s at IE to 0.8 m/s at DC, with RW."
0,Pt.
1,Patient has tolerated PT treatment fairly well and has achieved most functional goals.
0,Pt previously communicated that discharge to occur if prolonged delay occurs.
0,"Pt was working towards discharge, however was hospitalized last week for a UTI, requiring early discharge."
0,Reviewed HEP with patient and caregiver and all are compliant with her HEP and daily ambulation.
1,Patient has achieved or partially achieved all functional goals.
1,This had lead to improved gait pattern with increased B knee extension and decreased SLS time on R LE compared to L LE in weightbearing.
1,Patient made minimal progress with physical therapy intervention.
1,Agreeable to discharge as goals met.
0,Richard and his wife have been educated on using their Amazon Echo to participate in an exercise class 3-4x/week.
0,Patient was provided with HEP in order to reduce the functional decline and optimize patient current functional abilities.
0,Pt has good understanding of strategies to use to prevent FOG (freezing of gait) during mobility activities.
0,The patient has a chronic complex history of back and multi joint pain which fluctuates daily and within a day.
0,declination of services for 2 weeks.
0,Patient can continue transfer practice and ambulation with caregiver assistance.
0,Patient was unable to complete fall recovery on evaluation and is currently independent.
0,Patient could benefit from continued skilled physical therapy.
0,"Per communication from pt wife last night, pt is being admitted to Bel Air Manor in Newington today for rehab."
0,The patient has met the goals established at the start of care.
0,She is independent with transfers and can get up from all household surfaces without UE support.
1,Pt has achieved PT goals & doesn't need skilled PT
0,Pt.
0,"David, 84 years old patient referred for skilled PT due to recent onset of functional decline with history of falls."
0,"Extensive education provided on benefits of exercise, but pt is unwilling to progress beyond seated HEP and gait training."
0,Patient sustained a fall in her apartment on 1/9/22 resulting in elbow fracture and dislocation.
0,"In addition, pt is taking multiple medications with possible side effects of dizziness (Dorzolamide),  dyspnea (Levothyroxine), dizziness (Furosemide), and tremor (Albuterol)."
0,"Education provided to ensure pt is comfortable and safe on their own for the week since last treatment visit, and patient has not needed to reach out for additional visit prior to discharge."
0,Transferred to medical A for an Open wound  Patient recieved only 1 session of therapy
1,FOMs showed similar with 5 times sit to stand improvement from 23 sec to 14 sec TUG test improved from 27sec to 16sec patient specific function improved from 3/10 to 9/10 patient will continue to work on long term goals using HEP
1,Patient has been educated on stretches to improve posture and avoid further postural deficits.
0,She is now independent with ambulation and demonstrates adequate LE strength and balance.
1,"At this time, he has made generalized improvements in his flexibility, ability to assist caregivers w/ rolling, sitting balance, and with hoyer transfers to/from his WC and bed."
1,PSFS improved from 2.3 at IE to 6.5/10 at DC.
1,"Pt cont limitations with balance activities, as shown in FOM (4STAG), however has greatly improved."
1,"Pt demonstrated great improvements in strength, endurance and balance as noted by his TUG score, 5x chair rise test and 6 minute walk test."
0,"Due to medical complexity and chronicity of conditions, pt may benefit from screen in 3 months to assess status."
1,Patient fall risk has decreased as noted by the improved TUG score.
1,Pt has improved independence and activity tolerance during functional transfers and household amb c modified assistance c improved technique and safety awareness
0,Pt's ALF nurse called therapist to confirm hospitalization and request D/C from services.
0,Pt.
1,has been seen in physical therapy services since 2/11/22 to improve functional balance and decrease risk of falls.
1,"Pt has made good progress since starting PT with incr B LE strength improved posture, gait and function."
0,DC PT.
1,Upon evaluation pt demonstrates improved bilateral LE strength and decreased radicular symptoms.
0,Mary Jura 70 years female was referred to skilled PT due to recent onset of functional decline after falls in the house and outside.
1,Pt made minimal progress with PT in the time being seen.
0,was DC early due to patient is will travel to Florida for vacation.
0,Patient was provided with HEP to continue after discharge and is able to demonstrate and carryover the HEP and educated on safety during transfers and safe ambulation using RW within the house and outdoors.
0,"Pt initially demonstrating minimal participation in PT, but with PT scheduling with pt daughter present during PT sessions, pt has increased participation last 2 sessions."
1,She has improved LE strength for hip abd tested in sitting.
0,Pt to be discharged at this time.
1,"Pt has met most all goals with ind with transfers, stairs, and amb with most appropriate AD and has pain in shoulders, left hip, and low back more under control and manageable."
0,Pt's case has been on hold waiting for w/c delivery with order completed 5/10/22 due to hold up with receiving necessary documentation/signatures andinsurance approval process.
1,"Independent in walking and in turning using SPC 5.Significant improvement of balance to fair/good with ambulation and transfers using her SPC 6. ascend and descend stairs using minimal assist Patient has reached maximum functional capacity as to ambulation, transfers and ADL's."
0,family is independent in HEP and HAP.
0,No further skilled PT needed at this time
0,PT will follow up with facility on further therapy needs once pt is discharged from Select HH services.
0,Pt has increased independence when ambulating in MC unit c good safety awareness and acknowledging safety hazards.
0,Pt able to complete (I) HEP.
1,Patient met/partially met all goals and was mainly limited by safety awareness carryover 2/2 progressed dementia following her COVID-19 dx.
1,"P and CG have achieved goals for level of assist with ambulation, proficiency with guarding and improved with FOM's to point of being considered back at baseline with ambulation, stability with household management and functional strength."
0,Pt is to continue with his HEP and daily walking upon discharge.
0,"patient is a 72 year old female, resident in a senior living community."
0,Patient was admitted to Stamford hospital after a fall in her home.
1,"Pt and CG demonstrate competence in HEP, and has reached maximal functional potential, therefore there is no need for continued PT services at this time."
0,Pt is new to group home since 11/21.
0,Pt requests to stop Therapy and will consider surgery.
1,"Pt able to improve lateral stepping by reducing dragging, and requiring reduced UE support for stability."
0,"She had multiple set backs during her POC due to hospitalization, general FOF, and mild self limiting behaviors."
0,I couldn't do anything.
1,Patient had initially made great progress with skilled therapy.
0,Client can safely navigate steps (up to 10 without rest) using a handrail and SPC safely and endorses safety recommendations to install a rail in sunroom to maximize safety when negotiating steps and decrease risk of falls and fall related injuries.
0,She would benefit from continuation of HEP.
0,Discharge from skilled PT at this time.
1,"As a result of skilled PT services, patient has made improvements in B LE and UE strength, dynamic balance, bed mobility, transfers, ambulation, and activity tolerance."
0,The patient is a 71 year old male that has participated in 31 PT sessions.
0,Pt will be continuing physical therapy at new location.
0,Core and LE strength has increased as noted through manual muscle testing.
0,He and wife go out on weekends for socialization/daytime outings and doctors appointments as needed and wife is able to carry over ambulation and transfers safely as well at this time.
1,"Pt  has shown improvements in strength and muscular endurance in BLE as evident by MMT and 30 sec STS, has reached max rehab potential during household and community ambulation c RW c SBA for safety, has shown some improvements in  TUG and PSFS."
1,"patient achieved the following: 1.Improved strength on Hip flexion, knee extension, DF 2.increase CV endurance on B UEx 3.Indpendent in sit to stand transfer   4.Independent in walking using rolling walker, SBA with the use of SPC  5.improved in using stair lift done independently 6.Good balance as to sit to stand transfers, ambulation patient was provided with HEP to continue after DC to prevent future decline"
0,"Patient is aware that her oxygen saturation frequently drops with activity, but can perform deep breathing exercises to raise her oxygen saturation level into the 90s during seated rest breaks."
0,"At this time, pt has reached a plateau in progress and is appropriate for discharge from PT."
0,possible that energy levels lower due to cancer treatments.
0,The patient does remain impulsive with poor safety awareness with education to avoid higher risk position.
0,Pt was admitted at the hospital.
0,She is more alert and participates in coversations significantly more than she had when PT started.
0,William Morris 79 years old male referred for skilled PT due to recent onset of functional decline.
1,Pt able to ambulate for short distances on multiple occasions with clinician to improve LE strength for transfers and mobility.
1,"Since the start of the plan of care the patient has improved mechanics, strength and safety with functional mobility including chair approach and accessing bathroom with SPC."
0,"Pt was progressing back from a decline in late December/January related to acute kidney disease, but has transitioned to hospice so this plan of care ending."
0,"Pt needs min with sit to stand transfer  and ambulation, and stand by assist with stand pivot transfer assist."
0,Education provided to have clinician return if patient willing in the future.
0,Was informed by pt's caregiver this past weekend that pt passed away.
0,Pt requiring less assist for all mobility.
0,"She has been non-compliant with performing HEP between visits, had a change in medication which had a negative impact for a short time, prefers not to log roll."
1,"During treatment patient achieved all goals established at initial evaluation while demonstrating improved BLE strength and range of motion, improved safety technique and Independence with bed mobility and transfers on/off variety of surfaces throughout facility, improved ambulation distance with patient initiated rest prior to onset of discomfort/fatigue, decreased gait deviations, improved posture and safe utilization of assistive device on both indoor and outdoor surfaces."
1,Pt reached goals for 4SBT and Chair Rise Test demonstrating improved safety and reduced risk of falls.
0,Patient is admitted to the hospital due to bowel obstruction and possible to undergo surgery.
0,Educated pt and spouse heavily today on HEP and standing program follow through.
0,Increased independence and technique during bed mobility and STS transfers c modified assistance.
1,"Improvement of B UE strength and function with decr report of pain (noted by objective report in last 8 tx notes), however unable to quantify with status update 2/2 unexpected discharge from recent death in pt's family."
0,"bed mobility SBA, transfers SBA, ambulation with wheeled walker secure footwear SBA , min cues in narrow pathways."
0,"Pt has progressed with independence and safety with all functional mobility and no longer requires skilled PT services at this time, in which recommendation to continue with HEP and OT services to address additional functional deficits."
0,Pt will return home with 24 hour caregiver and will require visit nursing agency along with HH PT services.
0,Client has shown a 2.5 point increase in the PSFS achieving 8.5/10 which indicates decreased risk of hospitalization.
0,Pt unable to tolerate two therapies at this time1
1,"As a result of skilled PT services, patient has demonstrated improvements in B LE strength, balance, bed mobility, stair negotiation, and ambulation."
1,"During DC evaluation patient was able to achieve the following: minimal assist as to sit to stand transfers, minimal assist as to ambulation without the use of AD, with minimal risk of fall which demonstrates minimal assist as transfers and ambulation to prevent increase risk of fall related injury."
1,Pt has plateaued with PT to date.
0,"Patient referred to PT for balance training, therex and gait training."
0,FR shows increase balance fortransfers and amb.
1,Pt achieved PT goals & doesn't need skilled services
0,This is a 72 y/o female that resides in SLC.
0,Pt.
0,Clinician entering unexpected early FMLA.
1,"Pt shows improvement in all FOMs such as 4SBT, Chair Rise Test, and PSFS which contribute to improved functional mobility and reduced risk of falling."
0,"Patient requires supervision for bed mobility , transfers and gait."
1,is able to go out to MD appointments and shopping daily with her caregiver demonstrating improved activity tolerance and has not had any falls.
0,is now able to continue HEP and balance training with assistance of his daughter and PCA.
1,He is now independent with HEP and will continue to perform exercises for make further gains.
0,"During PT evaluation patient presented with decreased LE strength, decreased static balance, and decreased endurance."
0,Pt and son would like to be discharged as therapy with FOX is no longer covered by their current plan.
1,Pt has achieved PT goals & does not need skilled services
0,Pt was admitted to the hospital after getting COVID and is currently getting visiting nurse services at home.
0,Patient is admitted at the hospital and is receiving Med A services.
1,"Balance has also improved but SLS remains below normal therefore, therapist  recommended continued use of cane for ambulation."
1,Patient has shown significant progress with transfers and staff report decreased strain and improved safety when transferring.
1,He has demonstrated plateau in functional gains and has reached maximum rehab potential at this time.
1,"Pt demonstrates significant improvements in B/L LE strength especially strength and motor control on the RLE for improved functional mobility including STS, floor transfers and gait as well as improved safety with d/t increased balance."
0,pt has been admitted to hosptial due to c/o overall discomfort
0,"Primary mode of mobility in her room is ambulatory with RW, when she leaves her apartment alone sheutilizes a scooter."
1,Pt has poor rehab potential and husband needs to come to terms with her limitations and need for increased care.
0,He was staying in a hotel due to apartment flooding for most of treatment episode but was able to be reacclimated to his apartment at end of episode.
1,"Pt and PT agree with discharge, as transfers, gait and balance improvements."
0,"Due to cognition and lethargy, patient had difficulty participating in many activities and since transitioning to Waveny she also struggled with anxiety."
0,He has cancelled last three PT appointments due to decreased "motivation".
0,She is unable to bear weight for transfers or ambulation and requires total assist in all aspects of care.
0,Pt ambulates 400 feet level and unlevel surfaces outdoors with rollator device require SBA.
0,Patient has reported she no longer has LBP since fall.
0,Pt hospitalized and DC to short term rehabilitation facility.
0,Patient was provided with HEP and training with patient demonstrating HEP Independently and recommendation made to attempt resuming attendance of group exercises offered at facility once quarantine is over and group activities resume.
0,Family declined continuing PT services
0,He is d/c'ed from PT services at this time.
1,Pt's PSFS score has inc to reflect overall inc confidence and improvements in mobility.
0,Pt.
0,Unexpected discharge.
1,Pt reported doing very well & wishes to do walking & home exercises by herself
0,Hence DC from service.
1,"Lana is 96 yr old female referred for skilled PT due to functional decline, impaired balance and difficulty walking Patient was provided with therapeutic intervention to improve strength, balance and ambulation."
0,No further skilled PT needed at this time
1,She has improved in stand pivot transfer status to independent.
0,At this point pt can continue POC with HEP to further strengthen LE and promote safe functional mobility.
0,Patient is able to perform HEP independently.
0,Custom w/c order was completed with NSM for custom tilt in space w/c 3/2022.
0,Pt was originally recertified with assumption that orthotic evaluation and prescription was required before discharge.
1,She had been making good progress in therapy and would benefit from continued PT services.
1,Patient has improved in static standing balance able to stand with eyes closed 30 secs with feet apart.
1,"Lois' progress throughout her POC was limited at times, in part due to prolongedUTI, fluctuating cognition and an absence of a CG present during many PT sessions to provide CG education for improved carryover outside of PT sessions."
1,Sam has shown some improvements since starting physical therapy.
0,"Pain, which was widespread and fluctuated in severity at start of care, is now minimal to none in low back and intermittently in knees due to OA."
0,Pt is Independent with transfers.
0,She is now walking farther distances with CGA at her waist and transfers independently.
0,Has transitioned to hospice services.
1,"As a result of skilled PT services, patient has improved B LE strength, dynamic balance, transfers, and overall functional mobility."
0,Able to discuss c Pt and verbalized good understanding and acknowledged about the discontinuation
0,PT also reviewed and provided with HEP printout for compliance and confirmed mastery with education.
1,Pt unable to make steady progressions over the last 2 weeks and accepting of discharge.
0,Clinician unsuccessful in convincing this client to perform any transfer or ambulation related tx despite extensive trials.
0,is able to enter/exit her apartment including steps with ww and supervision as well as ambulation up to mailbox and back with supervision.
0,"Joanne is a 89 yr old female, referred to PT due to a decline in walking, stairs and transfers."
1,Patient able to progress quickly and steadily to increase NM control and balance reaction to maximize safety when ambulating up stairs into home when without UE support to improve grocery carrying into home.
1,Pt/caregiver/daughter was educated with proper transfers and ambulation to improve safety with 100% carry over and HEP.
0,Bed mobility has been transitioned to CG at this time due to demonstration of 100% return of assistive technique for sequencing supine- sidelying-sitting when assisting pt out of bed.
0,PT will D/C pt's case as w/c will not likely be delivered for another 60-90 days per w/c vendor due to current shipping and production times.
0,Pt may be candidate for home care services due to change in status.
1,Pt has been able to steadily progress interventions relating to balance by increasing dynamic activities allowing for improved safety with dynamic movements of stepping laterally at counter and sink.
0,Pt has HEP and walking program to continue with.
0,Patient was fearful to perform daily tasks and mobility.
0,Patient's lack of awareness of deficits and absence of motivation are primary hindrance to POC.
1,"From initial evaluation, patient has demonstrated clinically significant improvement in multiple elements of body structure/function, activity limitations and participation restrictions including: lower extremity strength shown by MMT and 30-second STS, balance shown by the 4-stage balance test, aerobic capacity shown by the 6MWT and improved independence with functional mobility including ADLs, gait, transfers, stairs and bed mobility shown by PSFS and PT observation of these activities."
1,Pt transfers with SBA at discharge improved from mod assist at evaluation.
1,Pt plan to maintain functional gains with HEP and continuing to attend FOX exercise class.
1,"Pt has reached her max rehab potential, has increased strength and muscular endurance in BLE as evident by MMT, has improved independence and participation during functional mobility as evident by PSFS."
0,"Client actively ambulating necessary distances (to and from dining hall, out for MD appointments with family as needed) and will continue to do so with min (A) and SPC at this time."
1,"Pt is now able to ambulate >1500 ft on both level and unlevel terrains/surfaces with SPC with SBA and is independent with stair negotiation, which has improved her ability to go to grocery store, attend church events and go out shopping with friends."
1,On time of evaluation pt required MIN assist and at the time of discharge pt is able to ambulate independently assist over 300feet using SPC.
0,HEP in place for strength and balance maintenance.
0,Pt has progressed to the point of discharge with in depth HEP and activity plan in order to continue to maintain and from sessions.
0,Client pending back surgery in July.
0,"Pt has become much more independant, is able to get up 3 flights of stairs to see the upper level of his new home for the first time, and has decreased his fall risk significantly."
0,Pt.
0,Unable to re-test 30s sit to stand test at this time due to orthostatic hypotension and reports of dizziness with change in position.
0,Pt has completed 49 tx sessions from 12/07/20 to 05/04/21.
0,Pt has not reported pain for at least 3 weeks at this time.
1,All balance goals achieved and indicate reduced fall risk at this time to negligible level.
0,Pt also gets stuck often while trying to propel herself with one hand and leg in manual W/C.
1,Patient is able to ambulate indoors and outdoors safely and without the use of railing during stair negotiation.
0,Pt is unable to consistently participate in functional mobility or follow commands.
0,Pt called stating she was in ER over the weekend and was transitioned to STR due to significant pain and difficulty walking.
0,Patient is discharged today.
0,She was transferred to acute rehab.
0,Pt current status SBA for stairs negotiation using LHR  and ambulation  using RW  x 75 ft .
0,"Pt would also benefit from OT referral to assist with home safety, ADLs, and fine motor skills as appropriate, but pt and spouse would like to hold off on OT for the time being."
0,Education has also focused on management of progressive/fluctuating nature of PD and need for regular exercise and physical activity including gait in order to assist with slowing the progression.
1,Patient is appropriate for discharge at this time due to functional plateau and maximizing gains from skilled PT services.
1,Pt has improved in SpO2 levels at rest and with activity.
0,"Patient was seen 3x's w/emphasis on negotiating a few steps to get in/out of the house through the garage,"
1,Pt has made strong gains in the past 46 skilled physical therapy visits.
1,"Pt has made progress since start of PT with reduced pain and improved mobility, however at this time does not feel that DC is appropriate due to continued falls risk."
1,"Patient has achieved highest practical level of function at this time, and skilled intervention is no longer required."
0,"However, she is now using her cane with increased frequency for all ambulation to help reduce her risk for falls and education has been provided on the importance of bilateral foot clearance to reduce risk for falls as well."
1,"discharge at this time, pt not making significant progress"
1,Pt has improved with amb from 250ft with RW and min cues to 560ft with RW and min cues.
0,Recommend continued PT services to reduce negative effects of hospitalization and prolonged bedrest.
0,"Patient is a 76 yr old, with a complicated medical history including pyelonephritis, hyperplasia, hematoma, A-Fib, 4 TIA's, septic PNA, HTN, DM II, depression, severe kidney infection, Chronic UTI's, neurogenic bladder, and CHF."
1,"Pt able to make continued progressions and was improving in ambulation distance, and functional outcome measures to improve mobility within community."
0,"Pt has demonstrated increased LE strength and dynamic balance, resulting in a reduction in risk of falling and hospitalization."
0,Pt presented to PT with difficulties with dynamic activites of gait and balance.
1,Pt achieved PT goals
0,Pt admitted to hospital with blood clot and has transitioned to home health.
0,is at a modified independent level ambulating in home with a ww and requires supervision for safety due to impaired confidence on ramp inside home as well as outdoors all with ww.
0,The patient has been fully educated and trained to complete daily HEP and home activity program in order to maintain functional ability and safety upon discharge.
0,pt has been hospitalized before any progress noted
0,Pt requested to be dc due to fear of contacting COVID19
0,DC PT at this time.
0,Surgery scheduled for Friday 1/14/22.
0,"Pt and spouse have also been educated re: conservative pain management strategies for B knee pain, which is rated lower and interferes less frequently with pt's standing and gait activities."
1,"She demonstrates ability to ambulate safely in the community with FWW as well as to transfer from all surfaces without physical assist, multiple attempts to stand at times."
0,Pt initially presented with significant L sided glute pain and reduced L sided abduction due to increased pain.
0,"Pt confined in the hospital d/t Fx hip from a fall last week, and will be sent to SNF for Rehab."
0,"Patient has been seen for skilled physical therapy services as prescribed by primary care physician to address recent decline due to injuries sustained during fall and post surgical procedure to repair damages to patient's spine with severe decline in functional mobility, increased level of discomfort reported by patient."
0,"Pt transitioned to HHA for wound care, thus reason for premature d/c."
0,Pt and CG verbalized understanding and agreement with discharge and instructions.
1,"Pt demonstrates improved balance, strength, and endurance with stair navigation, now independent with improved upright posture, decreased UE reliance, reduced SOB to perform task, and is now able to descend step over step."
1,"Due to recent fall he declined and fears of falling, hence the gait goal is partially achieved."
0,Client requesting to discharge PT services at this time as this clinician will begin FMLA.
0,"Pt has increased his gait capacity and ability to participate in dual task activities during gait, and his spouse demonstrates the ability to provide appropriate cues (inc step length, postural correction, alignment with rollator, etc.)"
1,Over the period of treatment session patient shown considerable improvement in overall function and However patient could not meet all the goals set at evaluation due to progression of PD and severe valgus deformity.
0,He is now appropriate for discharge and pt.
1,Pt partially achieved pt goals & not fully compliant w/ therapy at this time
1,"Through PT services, Patient has made significant gains in B LE strength, balance responses, and cardiovascular stamina - and does demonstrate overall reduced fall risk since beginning services."
0,"Additional safety concerns of medicaiton management to be addressed by upcoming SLP evaluation, this therapist assisted pt with scheduling to ensure carryover."
1,Pt appropriate for DC due to independence with HEP and plateau over the past few months.
0,"Pt has been seen for skilled PT to address her impaired balance, LE strength, and endurance."
0,Pt is no longer a good candidate for out patient services.
0,"PT has focused on functional activity: transfers, ambulation and fitness."
0,Found out recently that patient no longer was receiving Meloxicam or Gabapentin.
1,Patient has also demonstrated improved (R) hip external rotation ROM as a result of skilled intervention.
0,Pt able to negotiate 14 steps with step-through gait pattern using HR.
0,She is kept in soiled briefs for several hours as CG does not want to use hydraulic Hoyer more than one to two times a day.
0,Unexpected discharge.
0,Decreased safety awareness and discussed need for new brakes or rollator for safe use transfers.Client discharged due decreased participation in setting of increased behaviors.
0,Nanette is a very kind and warm hearted woman.
0,Unexpected discharge - client has been diagnosed with COVID and will be transitioned to home health agency at DON request.
1,"Pt has reached her max rehab potential, has excellent adherence and understanding in HEP."
0,Pt and PT agree with discharge at this time.
0,"Patient states that she no longer wants to continue with skilled PT due increased fatigue, and overall not being able to alleviate R knee pain."
0,Patient daughter was explained on the discharge plan and verbalized with understanding.
0,Pt discharged due to having cellulitis on L foot.
1,"At this time, Mr. Gallagher has recovered functional ROM and strength in bilateral LE, he is ambulatory throughout his home and for short community distances which allows him to pick up food from local restaurants."
1,Client presenting for discharge assessment on this date as she appears to have achieved maximal level of function / functional plateau.
0,Therapist called daughter Lynn to set up PT evaluation.
0,She had good understanding of how to best assist pt with bed mobility and transfers from multiple surfaces.
0,Pt transitioned to Med A services.
0,"Wife feels pt is at his baseline and due to his cognitive limitations, they have no further benefit from PT."
1,Pt has been able to increase NM control by performing 10 seconds on semi tandem stance for improved stability and safety with standing tasks.
0,"Patient requires continued skilled care to address deficits in strength, endurance, and balance - prior to surgery scheduled to remove cancerous uterus/bladder patient fell walking in hallway and broke L humerus."
0,Instructed patient and primary caregivers in increased opportunities for functional task.
0,"Education provided of the importance of increasing LE strength, balance, endurance, and mobility."
0,"Pt has experienced several hindrances to progress which prolonged time required for therapy, including several falls and hospitalizations."
0,"At this time, patient no longer requires skilled PT services."
1,"Mr. Beck made excellent progress overall with PT including increased BLE strength evidenced by 5x STS test, improved balance evidenced by four stage balance test and BERG, increased PSFS score, improved standing posture evidenced by wall occiput test and increased independence with functional mobility including bed mobility, STS transfers and gait."
0,Pt able to steadily increase LE strength and standing interventions throughout course of treatment.
0,"She has had increased difficulty with donning her compression stockings throughout the plan of care, as well as finding compression stockings with an appropriate and comfortable fit, in which pt plans to continue working with OT to further address independence with donning and doffing of compression stockings."
1,"Pt had initially shown good participation and improvements in his mobility and strength over first few PT sessions, but he has experienced a significant depressive episode over past 2-3 weeks."
0,Pt reports independence with HEP and ability to participate in morning strengthening class at SLC.
0,"As per pt's wife, pt will have HH services  when he gets home"
0,"Patient presented with decrease muscle strength, impaired balance, poor activity tolerance and endurance."
1,Pt doing well with bed mobility and transfers.
0,Pt admitted to Holy Redeemer hospital on 5/21 following sudden onset leg weakness and fall while getting into bed (assisted to floor by aide).
0,Pt has demonstrated progress since SOC.
0,Pt was dc to the hospital.
0,"Client to be discharged on this date as clinician has not been successful in engaging client in meaningful, consistent skilled tx during this reporting period."
1,The patient has plateaued with functional gains and is safe for discharge.
1,"During the course of treatment patient was provided with exercises to improve strength, improve cervical ROM, training to improve sit to stand transfers and gait training using RW."
0,"Pt's discharge was unanticipated due to hospitalization for low hemoglobin, dehydration and hypotension."
0,"At this time, pt has reached her max functional status."
1,"Patient has demonstrated partial achievement of most goals and great progress in static and dynamic balance, as she can hold tandem stance for 10 seconds and single leg stance for 7 seconds, has shown great improvement in gait speed and timed up and go score showing improved dynamic balance as well."
0,She is no longer w/c bound.
0,Patient is to coordinate with engagement for use of nu step for fitness.
0,"At this time, pt's electric wheelchair is medically supported as an assistive device for her due to her complex medical history and physical functioning."
0,"Pt only seen for 2 skilled PT Tx session, family allowed 2 visits only d/t high copay, Pt has been educated to use RW to the dining with escort and nurse on this facility has been informed about added POC to decrease decline in function, Pt d/c today for financial reasons."
1,"Patient also made great gains in his balance, demonstrating ability to maintain tandem stance for 8 seconds, compared to holding semi tandem stance for 5 seconds at evaluation."
0,Pt discharged due to change in baseline level and will be transitioning to Masters in Home Care agency.
0,HEP was provided to patient and daughter.
1,"The patient has partially achieved goals on TUG,MMT and PSFS score."
1,"Patient made mild improvement in muscle strength, requires moderate assistance for transfers and is able ambulate 60ftx 2 times with a rest break using RW with varying assistance from mod to max assistance."
1,CG and pt now able to progress independently toward any remaining deficits.
0,Pt at this time has become independent with HEP.
1,"Since previous PR, patient has shown improved management to LBP/paresthesias; he shows good compliance/adherence to HEP, including nerve glides to address pain behaviors."
0,Pt experienced L humerus fracture and is in short term rehab.
1,Pt was able to progress towards more dynamic interventions and increase SLS time for 10 seconds on each foot to allow improved improved stability with ambulation and dynamic activities of balance when performing ADLs.
1,has improved Tinetti assessment score from 15/28 to 24/28 significantly improving standing balance.
0,Pt will be discharged at this time.
0,"client, wife and caregiver educated on HEP and HAP including walking program and stair negotiation."
0,"Patient has been seen for skilled physical therapy services as prescribed by primary care physician to address recent decline in functional mobility, increased level of assistance required for daily tasks, increased risk for falls s/precent fall."
1,"Pt would benefit from continued skilled treatment to manage muscle tone, increase active indpendent control of BLE's during gait, improve assistance with transfers and ambulation."
1,Richard has made fair progress towards all outlined goals during his POC and is currently likely at his highest functional capability.
0,Pt.
0,Pt refused further PT services
1,"Pt has made slow return to baseline function since recertification, with some fluctuation in functional mobility and LE weakness, requiring continued close monitoring and adjustment to POC."
1,"Patient was also able to achieve the goal set for UE with overall score improved to 4+/5 in the UE, which was 3/5 LE and UE 3/5 during initial eval at upper and lower extremity.Pt also shows improvement in FOMs  5 times sit to  stand test was evaluated at time of initial evaluation and found to be at high risk of fall."
0,Symptoms management for stiffness and discomfort was also addressed.
0,The KX modifier has been applied because Mrs. Chassler exceeded the annual therapy cap.
0,"Caregiver has verbally and physically demonstrated good carryover of HEP during PT sessions, however reports patient frequently refuses to participate in HEP due to LE pain."
0,Patient and caregiver were educated on HEP to be able to able to carryout after discharge and for continued carryover.
0,Patient has been admitted to the hospital d/t acute hip pain and inability to transfer.
0,"Discussed that when he is more comfortable with sitting at the EOB, PT may be able to resume and progress his exercise programming."
1,Pt's LE strength and mobility has improved which agrees with improvement on FOMs.
1,Patient has had an overall improvement in his knee pain since initial evaluation.
0,Needs max cues in reminding patient to keep an upright posture during ambulation to be able to prevent forward trunk posture and increase risk of fall.
0,Pt has met his PSFS and 30 sec sit to stand goals.
1,"Due to achievement or partial achievement of goals, pt is deemed appropriate to d/c to HEP at this time."
0,"Pt cont to demo difficulty with functional transfers and cont to require power chair training, however Pt has stage 2 pressure sore and will transition to skilled nursing for wound care, they will also cont Therapy."
0,"Pt noted with slight knee pain during middle of the course of PT, but has not reported any pain for the last month of treatment visits."
1,"Pt has reached all rehab goals, has increased strength in BLE as it indicates in MMT and 5x STS, has improved balance as it indicates in TUG."
0,Pt to be discharged at this time.
0,Spoke with patient's daughter and the family has decided to move to comfort measures only as the patient has been declining.
0,Recommend pt continued to perform HEP with assistance from wife.
0,"70 yo male patient referred to skilled PT services with recent diagnosis of Parkinson's Disease in Nov 2020 with deficits in ambulation, transfers, dynamic balance, strength."
1,"Posture has improved as noted by wall occiput measure, LLE strength has increased as noted by MMT and hamstring length has improved over course of care."
0,Pt educated to continue applying heating pad and follow up with MD .
0,Unexpected discharge.
1,She has shown significant progress with her TUG score demonstrating >60% improvement in the fall risk score.
1,He made gradual progress throughout the POC.
0,Pt and PT agree with discharge at this time.
0,The pt is being d/ced today d/t reaching a functional plateau with skilled PT Tx at this point in time.
1,"Pt can ambulate x 200 ft level/unlevel uisng rollator SBA for safety, and Inde with transfers using rollator"
1,"Pt demo improved CV stamina with all activities with no SOB, however with proper pacing and rest period esp with static standing act."
1,Pt was provided with HEP/HAP in order to maintain gains made in skilled PT.
0,"Finally got a hold of CG Cora and she stated shortly after taking her to the hospital, she suffered from a significant stroke."
0,Reviewed exercises with patient and then pt.
0,"Richard's POC was hindered by chronic plantar R toe pain, that limited his ability to perform static and dynamic balance exercises throughout his POC."
1,Pt has made improvements in his strength and balance.
0,Clinician spoke with POA (daughter - Cathy) regarding status of this client's case and upcoming discharge.
0,Pt is for discharge as pt still receiving home health services under VNA.
1,Pt has reached all rehab goals.
0,Doreen Daum 77 yrs old female who is wheelchair bound was referred to skilled PT due to recent onset functional decline secondary to cerebral infarction.
0,Showing good understanding of HEP regimen and lessening pain with RX to date (no longer reporting any pain in knee/hip).
1,"Pt improved with all functional mobility, now independent with sit<>stand transfers with improved technique and with ambulation without L hip pain."
0,"Pt has recently had a decline in his health condition causing chest pain/tightness, increased SOB, and fluctuations in his vitals which have significantly limited his participation in therapy sessions."
0,Pt demonstraetd 100% carry over with HEP
1,"At this time, pt has partially achieved or achieved most goals and has reached max rehab potential - recommend d/c to HEP - pt in agreement and in full understanding that needs to continue with activities daily."
1,Patient has achieved highest practical LOF with skilled PT intervention.
0,Pt discharged with HEP though carryover has been very limited.
0,Pt is D/C for this reason.
1,"Since evaluation, patient has made considerable improvements in his strength, balance, and performance offunctional activities."
0,"Pt able to initially make progressions with ambulation distance, gait pattern, LE strength, and NM control."
0,"Provided extensive education to pt on benefits of receiving physical therapy services and the positive impact of exercise on depressive symptoms, but he is requesting discharge from PT at this time."
0,"She is ambulating with the cane indoors and outdoors and her pain levels are much lower, improving her overall quality of life and nearly restoring PLOF."
0,Pt chronic respiratory status limiting pt ability to progress with gait distance due to SOB.
0,Addressed hindrances with education in HEP instruction and discussed value in upping overall activity levels and incorporating more B LE WB Activity and B LE WB activity.
1,Pt has reached her max rehab potential.
0,educated on HEP and HAP including walking program and stair negotiation program.
0,Pt's family and aides were educated on her HEP and daily participation.
1,"Pt has achieved highest practical level of function and is unable to progress 5X STS, gait speed, or TUG scores d/t cognitive impairments and generalized lethargy."
0,Pt to be discharged to HEP at this time.
1,He had recent decline in transfers from min cues to moderate A after falls over the weekend but this week improved to min A from higher surfaces (i.e.
1,"Pt's TUG score improved, indicating improved balance reactions."
0,"pt is s/p fall and was hospitalized with hip fx, is now in rehab for unknown period"
0,"Naz convent, and by therapist, however choosing to not change any medications at this time."
1,"Patient is has the physical ability to perform all functional mobility without physical assist however due to decreased safety awareness and limited with carryover 2/2 her progressed dementia it is PT recommendation that she be supervision for all functional mobility including but not limited to stand pivot transfers, STS transfers, toilet transfers, and community mobility to and from all meals."
0,Patient is able to stand for more than 30 secs with feet apart and feet together with eyes open and closed with good stability.
0,"At this time, patient no longer requires skilled PT services."
1,"gait: improved from 50 ft w/ RW minA to 235 ft w/ RW min A mostly for cueing for postural correction, safety and directional changes/obstacle negotiation at DC."
0,PSFS shows increase amb and standing.
1,"Patient partially achieved the goals established for FSBT, 30 second sit to stand test, and PSFS."
0,Patient continues to require significant assistance with all mobility.
0,DC PT.
0,She is now independent with both.
0,"Nonetheless, pt and CG educated on continued need for skilled care with OT skilled services and ST services due to remaining mild-mod risk of falls, difficulty and impairments with ADLs and overall cognitive impairments due to Dementia."
1,He demonstrates improved ability to ambulate but continues to fatigue after short distances.
0,Pt discharged as he is moving to another state.
0,Pt is now DC to cont HEP ind.
1,Was able to improve ambulation distance but gait quality and transfer performed were unchanged throughout duration of POC.
0,Pt under Med A
0,Pt DC due to start of homecare services.
1,"Since initial PT eval, pt demo improved BLE ms strength indicated by improved FTSTS and MMT scores, improved balance indicated by achieving Tinetti and improving TUG, improved CV stamina indicated b improved 6MWT score and ambulation distance with rollator and improved functional independence indicated by decreased cues and assist during ambulation."
0,Pt is not independent with HEP and will continues to make progress.
0,Pt was unexpectedly dc upon pt's request due to increase anxiety during PT session as agreed by his MD.
0,Over the last few weeks the patients performance has largely plateaud.
0,"Patient was making slow progress towards the goal, was able to stand with moderate assistance for 10-20 secs, requires max assistance for stand pivot transfers."
0,Pt making slow progress toward goals.
1,"As a result of skilled PT services, patient has made improvements in B UE and LE strength, transfers, and overall functional mobility."
0,"Therapist contacted Ralph's wife, Maria, to check on patient status as patient was still in the hospital last week."
0,Pt was able to demonstrated independence with final HEP when reading a printed copy and using a walker in front with chair behind.
1,"Pt has made gains w/ PT and has reached max functional potential, and pt is pleased with progress."
0,"At this time, Sam is still able to walk to/from the dining hall within his ALF and go out to run errands utilizing staff transportation."
0,She has been more confused and complaining of intestinal symptoms from medication for UTI.
1,The patient has plateaued in functional gains.
0,He was regaining his confidence when the PC he was living in closed down and he was moved to temporary housing in a PC outside of the area and then he tested positive for covid.
0,Unable to meet remaining goals due to unanticipated D/C.
0,Patient is in agreement with DC.
0,Pt educated on importance of continued exercise and verbalizes agreement.
0,All of this affects POC in addition to polypharmacy of 19 medications.
0,Pt continues to be fall risk and is at risk for skin breakdown.
0,patient decided not to continue PT services due to patient want to manage her vascular case and will resume therapy and required by PCP.
0,Pt continues to stand without engaging her brakes and is unsteady without walker.
0,"He is independent and consistent with all supine strengthening ex's at this time, and skilled care is no longer required."
1,"Pt also demonstrates improved compliance with HEP although is not fully compliant despite continued education, modification of HEP to exercises pt enjoys, and education on strategies to ensure completion of HEP."
0,His hospital mattress will arrive by the end of the week.
0,PT will discharge from POC.
0,Pt has increased strength in B shoulders as evident by MMT and excellent adherence to HEP.
1,Patient has progressed in the following areas: Tinetti score improved from 15/28 at evaluation to 21/28 at discharge.
0,"Patient given print out of home exercise program and was educated on proper form, dosage, and frequency of exercises to be done independently for long term strength and muscular endurance benefits."
0,Pt has reached max benefit from skilled PT intervention.
1,Patient is being discharged secondary to all goals met except for pt at SBA level with outdoor mobility w rollator walker and SBA for completion of written HEP.
0,"Patient has made progress in her ability to engage in exercise, activity, and most importantly ambulation since SOC."
1,Patient is independent with ADLs.
0,Pt has had greater difficulty with transfers.
0,Patient has reached his max functional limit demonstrating plateau stage of recovery.
0,"at the time of evaluation patient presented with decreased strength, balance, stability, difficulty with walking."
0,Patient is slow paced and requires increased time to complete an activity and requires rest breaks between activities.
1,Patient will be discharged with a HEP for long term maintenance of gains made during episode of care.
0,Called and spoke with patient on 5/4 to check on status.
1,"Pt cont limitations with balance and mobility and requires Assistance, however has greatly improved."
1,Pt also noted with improved ability and decreased fear to negotiate 4 steps outdoor with new installed handled bars with SBA as well as demonstrate improved willingness to participate in functional ADLs and thus demonstrating decreased CG burden and improved QOL for this patient.
0,Patient is being D/C due to plateau in level of assist required for all functional mobility goals.
0,"DC due to initiation of MedA services for wound care, RN actively performing evaluation at therapist arrival to scheduled session today."
0,"Her progress was slower due to pt having chronic pain issues, chronic GI problems and having to cancel therapy visits at times."
0,Patient is able to perform those daily exercises with guidance from caregivers.
0,"At the time of evaluation Patient presented with decreased muscle strength, impaired static and dynamic balance and gait abnormalities."
0,"Unexpected discharge, Pt at the hospital"
0,No reassessment done due to only having 1 visit post Eval and prior to DC.
0,Primary dx dementia.
0,Pt was progressing well with skilled PT until last week.
1,Pt achieved IND bed mobility in previous progress report.
0,Caregivers have been well educated in safe transfertechniques and how to best assist pt with all mobility.
1,Pt in agreement of discharge at this time as she is able to improve mobility in multiple directions to reduce risk of falls.
1,"Although she has not demonstrated improvement in her Functional Reach Test, she has demonstrated improvement in her Four Stage Balance Test via performance of Tandem Stance, demonstrating her reduced fall risk."
1,"Goals for transfers, gait marked partially achieved secondary to patient's usual caregiver not being present at time of discharge."
1,Pt has achieved PT goals
0,"As a result, patient no longer requires skilled PT services."
0,Unexpected discharge.
0,Pt in advanced dementia & doesn't comprehend interactions lately became very combative & resistive to exercises & is not cooperative.
0,PT to DC to his HEP with pending neurologist appointment in the future to raise these concerns.
0,"During quarantine patient experienced a fall which resulted in him going to the ER and then being discharged to rehab, and needing to be discharged from current PT POC at this point in time."
0,Educated his daughter on need to obtain new orders once appropriate for outpatient PT due to change in status s/p hospitalization.
0,Formal reassessment unable to be performed due to nature of DC.
0,Will discharge per request.
0,Client participating in facility exercise and walking program in memory care unit.
0,Pt reported switching to different agency for PT services as per her convenience along with aide helper services
1,"Patient has been making steady progress toward goals established at initial evaluation while working on improving BLE strength, balance, endurance, gait training, transfer safety, stair safety."
0,HEP reviewed with pt and caregiver stressing compliance for over all wellness and health of pt.
1,"Patient given print out of home exercise program and was educated on proper dosage, frequency, and proper form for all exercises included to be done independently for continued functional gains beyond the date of discharge."
1,"Pt would like to be able to ambulate with a cane, however, is unsafe at this time so she would like to continue with wellness services."
0,"Patients caregiver was educated on LE exercises, sitting positing in recliner, safe transfer techniques, and ambulation with the help of patients daughter."
0,Pt can now safely access basement workshop to resume hobbies with safe stair navigation.
1,Client appears to have achieved maximal level of functional potential and is consistently ambulating outdoors and in community with spouse.
0,Patient reports has been standing with caregivers outside of therapy.
0,"Her mobility is chronically affected by weakness in her R hip and foot drop, likely due to nerve damage in her spine, as well as neuropathic pain in her feet."
1,patient has made good progress in POC and has achieved max functional potential.
0,Patient tolerated standing for 5 minute duration today holding onto grab bar.
1,"During treatment patient made steady progress toward goals established at initial evaluation while demonstrating improvements in bilateral lower extremities strength, improving standing tolerance, overall activity tolerance, decreasing level of assistance with transfers, improving ambulation distance on both indoor and outdoor surfaces."
1,"Pt has made significant progress t/o POC including now independence with transfers, amb with rollator for 240 ft+, and ability to navigate 2 stairs."
0,"Pt has been educated on HEP, proper body mechanics, and balance reactions t/o all activities and demonstrated appropriate knowledge and safety w/ all movement patterns."
1,"BLE strength improved and trendelenburg gait is still present, but not as pronounced."
1,"Overall, patient has made good progress since initial evaluation, demonstrating improvements in gait mechanics, trunk control, LE strength and has experienced fewer falls since beginning physical therapy."
0,He had better motivation and interest in physical activity.
1,Patient has progressed well and met all goals fully except achieving ability to negotiate steps to upper floor of home.
0,He will continue to benefit from performing HEP and practicing proper safety awareness techniques he has learned throughout therapy.
1,"Pt evaluated but then had to be discharged within two days due to requiring increased medical need for wound on B feet, due to potential infection."
0,She did begin to have increased right LE discomfort related to vein issues and increased shortness of breath which following MD visit was related to " fluid around her heart" per her daughter.
0,"Pt has been able to decrease pain levels where it no longer affects her waking up in the morning, and has been able to increase hip abduction ROM."
1,Pt has demonstrated progress towards all goals in the plan of care resulting in either partial achievement or achievement of all goals at this time.
0,"at the time of  evaluation patient presented with impaired strength in BLE, reduced functional activity tolerance, reduced balance, difficulty in bed mobility, difficulty in transfers and walking with rollator walker."
0,"Due to plateau in progress, pt is deemed appropriate to d/c from skilled PT services at this time."
0,Pt has progressed well with PT to date.
1,She is 100% independent with her HEP and has nearly met all PT goals.
0,DC PT.
0,Pt with unexpected D/C 2* hospitalization and SNF admission.
0,She has a cane and per patient she does use it on occasion in her apartment.
0,"Her chronic bilateral knee pain has been a limiting factor to progressing prolonged gait distances throughout POC, but it has significantly decreased since initial evaluation with regular cortisone injections."
0,Pt transfers with supervision from chairs in facility.
0,"At the time of  PT evaluation patient presented with decreased strength in BUE, BLE, chronic pain in left knee."
0,Pt is a 90 y/o male residing in Paramount Senior Living ALF.
0,Unexpected discharge.
1,"Pt has achieved FOM scores aside from 2MWT, though shows improvements in aerobic capacity, by MDC, when compared to baseline."
0,She continues to benefit from min cues for safety and pain management with transfers.
0,Pt presented to PT with the primary goal being able to perform 3 stair negotiation in order to access daughter's home.
1,"The last couple visits prior to changing to hospice, patient had started to make some progress and was not complaining as much of knee pain which was biggest complaint."
1,The patient verbalizes and demonstrates safe use of assistive device and is able to ambulate with modified independence on level surfaces.
1,Pt has met goals and no longer requires skilled PT- she has daily HEP to follow to maintain currentmobility level
0,"Patient progressing with LE strength, NM control, endurance, and reduced pain levels throughout treatment."
0,Pt and caregivers have good understanding of transfer techniques and use of walker for ambulation.
0,"At this time, per discussion w/ POA pt to continue on skilled private pay services to continue to assist w/ HEP."
0,"Pt able to make inconsistent progress towards goals, largely due to her apprehension of falling."
0,"Her daughter tries to visit daily, but only has her walk short distance to the car for MD appointments."
0,Pt demonstrated 100 % carry over with HEP.
0,Pt has been discharged from hospital and has returned to ALF.
1,Pt has made many gains and experienced changes in functional decline as well as reaching of baseline functional status.
0,"David has shown fluctuation in status related to bed mobility assistance, LE strength, sitting balance, and functional independence related to his neurological dysfunction."
0,Instructed by Practice Liaison to discontinue PT service due to OON insurance issue.
0,is independent with a HEP for maintaining and continuing LE strengthening.
1,Pt has made great progress with therapy and is independent with HEP at this point.
1,Reduced pain and improved activity tolerance in L shoulder during functional tasks and able to return to PLOF.
0,"During which time LE strengthening, standing balance transfers and ambulation have been addressed."
0,Discharged d/t inability to participate fully in POC.
0,Patient provided with written HEP to maintain current functional mobility level and B LE strength.
0,"Per ALF Nursing director, patient to be discharged to Med A for skilled nursing for pain management."
0,Pt is I with written HEP for LE strengthening and family will encourage performance to increase compliance.
0,"Pt educated on MedA switch and reconnect call for resuming PT, pt verbalized understanding."
0,"Pt's cervical region pain is resolved, as she does not c/o pain often and is able to utilize lidocaine patches or Icy Hot, etc., to assist with pain management."
1,"Pt demonstrate gains after receiving skilled PT, pt is now independent with  gait on level surface using no AD  and functional transfer such as sit to stand transfer on different surface and stairs negotiation, Pt also states that pain on the lumbar area have decreased improving her posture and mobility."
0,Wanted to stop therapy until investigations/medical Rx are done.
0,Patient was admitted to Hospital and is now receiving visits with Med A services
0,"Prior to DC, reviewed pt's HEP, suggestion to increase pt supervision to ensure her safety, and reviewed instruction that pt should under go further cardiac evaluation to determine reason for impaired vital signs response to functional mobility."
0,"Pt able to steadily increase ambulation distance, and perform ambulation with walker on unlevel surface of grass."
0,Patient has tolerated PT treatment well and without incident.
1,"Pt reports independence with HEP, has made good progress towards goals, and is appropriate for discharge from PT at this time."
0,"Pt had been slightly increasing LE strength, and being able to slightly increase volume of STS in one set as treatments progressed."
0,"Therefore, no further skilled PT needed at this time"
1,Patient has made good gains since IE w improved LE strength from 4/5 - 4+/5 to 5/5.
0,They are keeping her comfortable and waiting to see how she does.
1,"Pt is discharged from skilled PT services d/t meeting PT goals, indep with ADLs, and indep with HEP of therapeutic exercises."
0,educated wife and daughter on HEP and HAP including walking program and safe stair negotiation.
1,"Pt has demonstrated improved endurance, decreased back pain and improved mobility/posture, balance, and gait/stair mobility."
1,"Overall, pt is functionally able to drive, independently get into and out of cars, go to farm house, navigate steps, ambulate in grass and attend Penn State football games."
0,She also is managing home maintenance better without assistance and not relying on sitting in a wheelchair as she often did at SOC.
1,"patient has improved Muscle strength on B UEx and LEx, requires SBA to minimal assist as to sit to stand transfers and ambulation without the use of AD."
1,"As a result of skilled PT services, patient has made improvements in B LE and UE strength, dynamic balance, and overall functional mobility."
0,PT will follow up when medically necessary.
0,See previous progress note regarding status of goals established at initial evaluation and patient's current functional level.
0,"Pt's R ankle DF ROM remains limited, but pt is aware of need to address ROM (with seated heel slides and other ROM interventions)."
1,"At this time, pt has partially achieved most goals and has reached max rehab potential - recommend d/c to active participation to ALF activities to prevent decline in function."
1,"During the course of treatment patient was provided with skilled PT services to improve LE strength in supine and sitting, bed mobility training using sliding board and side railing to scoot upwards and to reposition on the bed."
1,Patient has improved bil LE strength to 4-/5 BIL LE improved from 3-3-/5 at evaluation.
0,"Pt was originally admitted for further muscle strengthening and gait training following multiple severe falls in her home, resulting in facial laceration and increased R hip pain."
1,"Gains include improved endurance noted by the ability to walk dog safely with RW outdoors for 10 blocks, improved LE strength per MMT, improved transfer and gait mechanics, improved balance noted in pt's ability to perform TA and right herself > than FOM's likely due to injuries sustained during treatment that increased global P and soreness."
0,The patient was having increased difficulty with functional mobility and increased frequency of falls.
1,Pt made good progress with physical therapy and is now able to safely negotiate his home and stairs with reduced risk of falling.
1,"At this time, pt has improved his ambulation tolerance to 50ft x2 with minA with RW, 30sec STS: 3 transfers, PSFS 7/10 and 3:30 of supported standing without complaints."
1,This has improved his quality of gait (improved step length and forward progression) and speed of gait which is another indicator of decreased risk of falls.
0,"At this time, pt's caregivers have been trained on HEP and understand compliance expectations to continue to manage pt's pain and mobility challenges."
0,Wife reports client is walking to meals daily and she verbalized importance of continuing to do so.
0,she continues to require max a from recliner and advised daughter to look into mechanical lift chair.
1,"He has overall declined in amb from 92ft with RW and min cues to 76ft and min TCs with RW and gait belt use and has improved in gait this week after decline s/p falls over the weekend.. PT has addressed pt/caregiver education in fall prevention, mobility with assistance and gait belt, HEP and HAP, wheelchair implementation and home safety environmental modifications."
1,"Attempted to engage pt to actively participate with mobility to assist caregivers during daily tasks however, pt was unable to improve mobility with instructions and assist."
0,No 30 second sit to stand was performed this date due to fatigue.
0,"Pt discharged on 8/24/2020 and experienced a significant functional decline evidenced by the following FOM performance at PT Re-evaluation on 8/26/2020: 30 sec STS: 1 transfer, PSFS 1.7/10, and 30 secs of supported standing with increased encouragement."
0,This clinician entering unexpected early FMLA at this time.
0,During days of increased fatigue pt able to reduce assistance to moderate instead of maximum for STS transfers.
0,"However, due to poor healing of recent skin tear, Select HH services will be addressing wound care and provide therapy for pt."
0,Pt.
1,"At this time pt would still benefit from skilled services, ambulation had demonstrated some improved technique and endurance however not goal level, and sit<>stand transfers demonstrated some technique carryover."
0,Recommended she call if she would like to restart services once she completes homecare services and she is in agreement.
0,Patient expired
1,"This indicates improved strength, despite 30s sit<>stand test with no improvement, however its purpose to determine improved strength is moot with stair navigation improvement."
1,Pt has made great progress since SOC.
0,Pt would like to just continue with HEP due to high copay at this time.
0,Hence patient is discharged from PT services due to recent hospitalization.
0,At this time PT is not useful.
1,She has met most goals ofPT and is ready for discharge at this time.
0,Pt is hospitalized & may get referred to hospice care
0,HEP manual provided and demonstrated with HHA verbalizes understanding on safe performance and safety with HEP.
1,Client has shown excellent gains since start of care.
0,Client unexpectedly discharged to Master's in Home Care on this date d/t significantly declining medical status and fall with injury requiring nursing attention.
1,"Over this episode of care, pt has made significant gains in all of these areas."
1,"Time in therapy services was too brief to note change, but he did exhibit good motivation and small improvements in coordination of movements thus far."
0,However at this point in time patient has reached his highest level of function.
0,Pt underwent GI surgery
1,is appropriate for discharge of skilled physical therapy as she has achieved herbaseline status.
0,This impacted his function over approx.
0,No progress made as only seen 3x total.
1,Outdoor gait safety improved though was limited d/t poor weather pt exhibits improved consistency and confidence with use of SPC both inside andoutside.
1,"Pt overall improved significantly with both balance and functional mobility, reducing fall risk and improving safety in home and community."
1,"Pts wall to occiput measurement consistent today, however has improved since eval indicating improved posture."
1,Pt has been able to reduce TUG time allowing for improved mobility within facility.
0,TUG demonstrates pt is at decreased fall risk at this time.
0,Patient was provided with HEP to continue to prevent decline and reduce the risk of falls.
1,"Pt has been provided with written/pictorial instructions for HEP to include seated hip ABD, seated hip flexion, seated scap retraction, shoulder flex/ABD table slides, seated trunk extension, seated heel slides, and STS; pt has been educated re: importance of regular exercise and need to continue with both strengthening and flexibility interventions to maintain gains."
1,"During the course of treatment patient was provided with exercises to improve muscle strength, balance, safe transfer techniques, and gait training with RW."
0,HEP in mat and in standing reviewed with pt and with good compliance.
1,"Pt has made gains with transfers and functional mobility, with decreased fall risk."
0,"Pt's multiple medical comorbidities that limit her functional mobility include COPD with supplemental O2 at 2L at rest and 3L with activity, pulmonary fibrosis, CHF, spinal stenosis, HTN, SI joint dysfunction, arthritis, PVD, h/o embolism R iliac artery, and B TKA."
0,Pt has demonstrated progress since SOC.
0,Pt requires the use of O2 supplementation continuously and during evaluation became moderately SOB after amb 40ft with RW.
0,"Pt is refereed for PT due to weakness,difficulty transferring and ambulating along with balance impairment and high risk of falling.FOMs shows the pt is at risk of fall and goal was set for the maximum functional level."
1,Pt was not able to ambulate at initial evaluation and is now able to walk with a RW with SBA for safety as he does not manage his oxygen tubing well.
0,Pt is independent with HEP.
0,Albert Stossel Jr 84 yrs old male diagnosed with Parkinsons disease was referred to skilled PT due to new onset of functional decline.
0,"Pt has made progress, ambulating more often and performing HEP indep on regular basis."
0,Client requesting for no further tx sessions and for this clinician to complete discharge paperwork at this time.
1,Pt strength has improved but goals of 4-/5 not fully achieved due to ongoing chronic effects of Myasthenia Gravis.
0,"Pt was admitted to the hospital today with dx of UTI, sepsis, bradycardia and lethargy."
0,patient was hospitalized due to undisclosed psychiatric reasons and is not able to resume therapyPOC at this time
0,Pt is not able to progress with skilled therapy and has already been provided with assist in getting a new W/C ordered to offload her body to reduce risk for pressure ulcers.
0,"Pt has had questionable commitment to HEP, however understands purpose."
1,"Pt has been able to make improvements to all areas of LE strength, NM control, mobility, and improved gait pattern as she has transitioned to using a rolling walker without use of platform."
1,Patient now presents with reduced fall risk as evidenced by improved BERG score of 48/56.
1,Pt has experienced some improvement in management of symptoms and pain related to myasthenia gravis and incomplete cervical SCI with these additional treatments as well as PT intervention.
1,Pt has made great gains with skilled PT and has achieved all goals.
0,Patient demonstrated independence with all exercises by the end of review.
1,Recommend continued HEP to maintain or improve ROM.
0,"She still requires supervision with outdoor ambulation due to instability and occasionally demonstrates decreased awareness, putting her at risk for future falls."
1,Pt has made significant progress.
0,Pt performing AROM prior to rising to decrease stiffness and rigidity from OA and PD.
1,"Has improved independence in step/stair negotiation at home and in the community s AD c improved technique, sequencing and placement."
1,"Pt was making minimal progress towards increasing LE strength, mobility, transfers, and balance."
0,"Pt hospitalized at Johnson Hospital due to difficulty breathing, switch to MedA requires DC at this time."
1,Client has demonstrated good progress with skilled services as evidenced by partial to full achievement of all goals.
1,PSF improved to 8/10.
0,She was seen for 9 visits and then discontinued home services for financial reasons.
1,Pt has made great progress.
0,pt was admitted to hospital with elevated blood pressure per MD
0,She verbalized understanding and agreement.
0,"Pt able to perform 10 seconds on SLS time, decrease TUG time, and overall increase NM control and coordination with LE tasks."
1,"Pt is no longer a fall risk at this time, and balance improvements are displayed with independence with ambulation both in home and over pavement and grass."
0,Now I can walk and use my legs."
0,She has now progressed with her function that she would like to now be able to progress to be more ind with ADLs and IADLs and therefore recommend OT services.
0,Pt and PT agree with DC at this time.
0,"Her husband is pleased as they are now able to go out to eat, not only because COVID is under better control, but also that his wife is now mobile again."
1,shows improved safety on stairs.
1,Pt has made excellent improvement with PT since referral.
0,She demonstrated very little carryover due to cognitive and memory deficits.
0,He presented to physical therapy s/p fall with closed head trauma complicated by LE weakness and restriction of ROM in bilateral LE - Left LE due to post joint replacement stiffness and R LE due to progressing OA.
0,Pt will requires min A and cues during functional transfers and ambulation c RW due to impaired cognition and in order to ensure safety at all times.
0,She reports that they were able to get in to see Dr. Moose last week and that Hospice started on Monday 08/30/21.
0,The patient and caregivers educated to seek treatment in the future if functional level changes or home exercises are no longer appropriate.
0,Pt transitioned to Salmon Brook for rehab on 7/8/22 per SLC nurse Amy therefore PT services DC.
1,"Despite pt with history of Dementia, falls and blood disorder with impaired functional endurance, pt slowly but consistently progressed and now requires decreased assistance and facilitation from CG for transfers from chair (SBA now from multiple heights and surfaces), able to ambulate with greatly improved distance of 450 feet with her rollator indoors with improved step length, foot clearance, upright posture and with improved gait stability."
1,Pt currently has achieved a level of balance and strength to do transfers and ambulation in apartment (couch to bathroom).
0,She is independent with HEP with CG encouragement and is safer with all bed mobility and transfers.
0,"He now demonstrates increased tolerance for ambulation indoors and outdoors, increased independence with indoor ambulation without AD, increased upright posture due to increased core strength."
1,Pt unable to achieve maximum benefit of skilled PT by being unable to participate in interventions of balance and stability due to fear.
0,Worsening freezing and rigidity symptoms have prevented longer worth while PT sessions despite changes in times of the day and varying medication times.
0,The patient has been admitted for Home health.
0,"At time of last PR, pt's DGI score was slightly lower and TUG score slightly slower, likely d/t difficulty with motor planning and processing of instructions."
0,CNA staff continuously used transport chair or old WC's to transport pt within facility affecting her standing tolerance and NM control.
1,Pt has demonstrated some improvement with physical therapy but d/t ongoing neurological conditions pt has had limited progress.
0,Pt is now DC.