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OVERVIEW
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Patient presents with complaints of
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Functional Deficits includes
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Driving
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Additional comments
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Perform Meal Preparation Deficits Status
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Additional comments
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Reach into Kitchen Cabinet Deficits Status:
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Additional comments
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Lift / Carry Laundry Baskets Deficits Status:
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Additional comments
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Perform Light Household Cleaning Tasks Status:
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Additional comments
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Sleep Disturbance Deficits Status:
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Additional comments
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Forward Bend to Complete Dressing Status:
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Additional comments
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Ascend/Descend Stairs to Bedroom/Basement
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Additional comments
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Walk Deficits Status: (Add comment detail)
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Additional comments
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Complete Yard Maintenance Deficits Status:
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Additional comments
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Lift or Carry Groceries into the House Status:
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Additional comments
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Squat Deficits Status:
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Additional comments
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Change Direction without LOB Deficits Status:
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Additional comments
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Multi-Task and Maintain Balance Deficits Status:
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Additional comments
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Other Comments
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PMH / PSH:
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Pain Rating & Progression
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Current
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Best
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Worst
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Progression
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ADL’s and IADL’s
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Patient Lives in
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Independent Living
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Patient Requires Assistance
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Patient requires assistance with:
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Occupation
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Work Status
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Work Comments
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Functional / Physcial Deficits
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Posture
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Other Comments
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Functional / Substitutions
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Compensates for limited neck AROM
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Patient utilize ITEM for ambulation
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Utilize arms for negotiating steps with rail sec
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Over utilize back when bend for light household
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Upper traps to compensate for poor scapula
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Now sits for daily tasks / not able to stand
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Using non dominant arm secondary to injury
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Other:
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Other comments
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Left Assessment
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Movement
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AROM
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PROM
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Strenght
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Shoulder Flex
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AROM
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PROM
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Strenght
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Abduction
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AROM
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PROM
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Strenght
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External Rot
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AROM
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PROM
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Strenght
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Internal Rot
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AROM
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PROM
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Strenght
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Externsion
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AROM
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PROM
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Strenght
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Elbow
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AROM
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PROM
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Strenght
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Supination
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AROM
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PROM
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Strenght
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Pronation
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AROM
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PROM
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Strenght
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Wrist Flex
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AROM
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PROM
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Strenght
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Extension
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AROM
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PROM
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Strenght
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Radial Dev
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AROM
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PROM
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Strenght
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Ulnar Dev
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AROM
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PROM
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Strenght
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Right Assessment
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Movement
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AROM
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PROM
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Strenght
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Shoulder Flex
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AROM
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PROM
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Strenght
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Abduction
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AROM
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PROM
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Strenght
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External Rot
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AROM
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PROM
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Strenght
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Internal Rot
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AROM
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PROM
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Strenght
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Externsion
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AROM
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PROM
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Strenght
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Elbow
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AROM
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PROM
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Strenght
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Supination
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AROM
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PROM
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Strenght
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Pronation
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AROM
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PROM
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Strenght
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Wrist Flex
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AROM
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PROM
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Strenght
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Extension
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AROM
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PROM
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Strenght
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Radial Dev
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AROM
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PROM
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Strenght
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Ulnar Dev
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AROM
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PROM
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Strenght
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Functional / Physical Deficits 2
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Left Index
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MCP
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AROM
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PROM
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PIP
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AROM
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PROM
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DIP
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AROM
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PROM
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Left Middle
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MCP
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AROM
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PROM
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PIP
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AROM
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PROM
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DIP
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AROM
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PROM
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Left Ring
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MCP
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AROM
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PROM
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PIP
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AROM
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PROM
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DIP
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AROM
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PROM
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Left Small
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MCP
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AROM
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PROM
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PIP
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AROM
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PROM
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DIP
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PROM
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AROM
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Left Thumb
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MCP
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AROM
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PROM
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PIP
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AROM
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PROM
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DIP
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AROM
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PROM
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Right Index
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MCP
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AROM
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PROM
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PIP
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AROM
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PROM
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DIP
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AROM
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PROM
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Right Middle
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MCP
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AROM
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PROM
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PIP
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AROM
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PROM
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DIP
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AROM
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PROM
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Right Ring
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MCP
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AROM
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PROM
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PIP
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AROM
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PROM
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DIP
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AROM
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PROM
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Right Small
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MCP
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AROM
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PROM
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PIP
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AROM
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PROM
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DIP
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PROM
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AROM
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Right Thumb
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MCP
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AROM
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PROM
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PIP
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AROM
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PROM
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DIP
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AROM
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PROM
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Edema
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MMT
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Opposition
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Functional / Physical Deficits 3
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5 Position Grip Test
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I
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Left
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Right
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II
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Left
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Right
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III
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Left
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Right
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IV
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Left
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Right
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V
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Left
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Right
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Pinch Strenght
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Lateral Pinch
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Left
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Right
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2 Point Pinch
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Left
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Right
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3 Point Pinch
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Left
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Right
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9 Hole Peg Test
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Left
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Right
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Other
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Left
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Right
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Grip Strenght
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Left
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Right
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Special Tests
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Observation
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Palpation
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Joint Stability
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Movement Pattern
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Posture
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Sensation
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To Be Tested Later
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With in Normal Limit
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If abnormal, enter additional comments:
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2 Point Discrimination Test
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With in Normal Limit
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Impaired
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Semmes Weinstein Monofilament Results
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Wound
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Wound / Scar
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Lenght
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Width
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Closed
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Open
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Drainage
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Treatment
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Treatment will consist of:
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Assessment
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Finding Consistent with Rehab Diagnosis of:
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The rehabilitation potential for this patient is
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Eval Assessment
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Assessment Goals
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Assessment Comments
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Progress Note / Plan of Care
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Frequency and Duration of Care
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Patient to be seen
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Times per week:
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Number of weeks:
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Plan of Care: Short Term Goals
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Short term goal 1
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Short term goal 2
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Short term goal 3
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Short term goal 4
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Short term goal 5
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# of Weeks Expected to Meet Goals
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Plan of Care: Long Term Goals
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Short term goal 1
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Short term goal 2
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Short term goal 3
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Short term goal 4
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Short term goal 5
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# of Weeks Expected to Meet Goals
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Prior Functional Levels
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Complete independence in the performance
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See Functional Deficits Below
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Functional Deficits Treatment Plan
|
|
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Treatment will consist of:
• • •
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Other
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Plan of Care Statement
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Plan of Care Statement
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Declaration
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Doctor agree with Plan of Care:
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