Treatment Provided: Total knee protocol to include instruction of HEP and performance of the following exercises: ankle pumps x 20, quad sets x 15, SLR x 10, sidelying SLR x 10, glute squeezes x 20, mini squats x 10, heel slides x 15. Reinforced proper posture and provided cues for safe lifting of items overhead throughout treatment., Provided verbal cues to correct for anterior translation of femur with squatting and to promote the appropriate body mechanics for sit- to- stand transfers and other functional activities., Instructed performance of squatting with a weighted object in order to improve sit-to-stand function. endstream endobj startxref We know how it is to feel trapped by the never-ending paperwork. In Touch EMR is a leader in web-based EMR for our practice. All rights reserved. Post estim to facilitate muscle contraction, patient was instructed in the following exercises to facilitate improved voluntary muscle movement. Patient is at risk for Key impairments include: decreased ROM and strength of the left lower extremity, poor balance and compensatory gait patterning, increased swelling, and pain with functional activities such as squatting, walking, and stairs. A well defined workflow for the front desk, clinicians, billers and coders makes this a one-stop shop for quick, compliant documentation and flawless billing. Maintenance Therapy: Top 10 Things to Know - Harmony Healthcare to progress with stability training, to decrease the risk of falling, to safely manage lifting # items at home, to independently don/doff clothing, to perform head checks in vehicle safely, etc.. 14. PHd$2 +4^{D=fO:%hWVuOq~4ssatP6 Patient completed standing Achilles stretch 3x 30sec with mod verbal cues for technique and to engage in pain free range. If you ever get audited, the fact that you are using ONC-certified EHR technology (CEHRT) will work in your favor. Increase of 5 degrees in L hip abduction was achieved through exercises since last reporting period. A: Lisa Miliken: There is a great list of suggested skilled terminology to use for different clinical scenarios on the ASHA website:http://bit.ly/1Xc5BD1. Why cant we just focus on patient treatment, and not be burdened by endless documentation? Support is always there when we need it, options to customize options to match our workflow are endless, clinicians find it simple and easy to use, front desk and billing love the integration between documentation and claims and compliance is built-in. Our focus was on glute activation prior to hip extension., Abdominal contraction prior to squatting (timing), A change in sequencing of abdominal recruitment prior to squatting improved lumbar posture and reduced pain., The patient was challenged in achieving proper squat technique due to balance deficits. Are you able to send the booklets by mail instead of having to download all of this on the computer? Physical Therapy Documentation Phrases: 12 Examples for - PTProgress 0 (Skilled terminology is highlighted in red.). When treating patients, use shorthand to take quick personal notes about your interactions and observations. The patient will tolerate feeding self with minimal assist, occasional verbal cues and hand under hand technique 100% of meals with occupational therapy to maintain current weight at ______ lbs. Physical Therapist: _______________________ Date:_________ Time: _________, Physician Signature: ______________________ Date: ________ Time: _________, Patient stated I am better able to sleep at night with less throbbing in my knee.
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