Professional Documents
Culture Documents
Treatment Note
Patient Name: XX
S:
Pt
was
met
in
room
while
completing
her
morning
hygiene
routine
and
was
agreeable
to
have
student
lead
intervention
session
as
part
of
her
fieldwork
experience.
Pt
verbalized
that
she
was
felt
she
was
doing
much
better
at
donning
her
socks
and
shoes
and
that
she
was
has
not
been
getting
dizzy
when
moving
from
sit-to-stand.
O:
Pt
was
seen
in
inpatient
room
for
6o
minute
OT
session
to
address
moderate
cognitive
impairment
and
to
improve
ADL
and
IADL
performance.
ADLs
&
IADLs:
Pt
demonstrated
making
her
bed
with
set
up
of
clean
linens
at
bedside.
Pt
then
sat
at
bedside
and
donned
socks
and
shoes
Ily.
Pt
ambulated
to
dayroom
Ily
to
complete
safety
awareness
task
of
recognizing
hazardous
situations
with
mod
I
required
for
increased
time
once
every
four
pictures.
Pt
was
given
skilled
instruction
on
how
to
push
herself
up
on
armrests
when
moving
from
sit
to
stand
on
her
way
back
to
her
room.
A:
Pt
demonstrated
increased
functional
mobility
while
ambulating
around
bed
and
increased
dynamic
standing
balance
when
securing
fitted
sheet
on
mattress.
Pt
showed
an
increase
in
dynamic
sitting
balance
when
bending
at
the
waist
to
don
socks
and
shoes
at
bedside,
pt
recognized
this
improvement.
Pt
demonstrated
an
increase
in
safety
awareness
throughout
safety
awareness
activity.
Pts
functional
mobility
from
sit
to
stand
is
improving
and
pt
reported
no
dizziness
after
moving
from
sit-to-stand
at
the
end
of
therapy
session,
which
was
consistent
with
pt
statement
on
orthostatic
hypotension.
Pt
would
benefit
from
continued
safety
awareness
assessment
and
ADL/IADL
intervention
to
increase
potential
for
return
to
independent
living
situation.
P:
Continue
to
address
ADL
and
IADL
performance
along
with
moderate
cognitive
impairment
1x/day
for
60
minutes,
everyday
for
one
week
until
planned
discharge.
Next
session
therapist
will
assess
UE
and
LE
dressing
and
grooming/hygiene
routine.