Question

II. ***Write the following information in a more clear and concise manner, as it would appear in the medical record. Include an appropriate subheading.

1. The patient walked 75 feet in the hallway of the hospital with the therapist lightly touching her back. She used a front-wheeled walker. The therapist was needed to help provide the patient with support to maintain balance.

2. The patient’s strength was 3/5 for the right biceps and 4/5 for the right triceps.

3. Upon arrival to therapy, the patient told you that she had been doing her HEP without any problems and really

felt like her ability to get in and out of bed has improved.

4. The patient said that her pain was 3/10 on a pain scale.

5. You performed an ultrasound to the dorsal aspect of the patient’s right foot. You used 3 MHz at 50% duty cyclewith the intensity set at 1.0 w/cm2.

6. The patient demonstrated the following range of motion measurements: active range of motion for the right elbow was 130° flexion and 10° of hyperextension.

7. Knee active range of motion was 100° flexion and lacking 10° of extension.

8. The patient propelled his wheelchair around the hospital, outside on the sidewalk, and up and down several ramps with you providing verbal reminders on trunk positioning for going up and down the ramps.

9. The patient was able to put her ankle-foot orthosis on and remove it independently. She was also able to independently check her skin for any irritated areas after she removed the orthosis.

10. You instructed the patient to perform 10 repetitions of each exercise as part of her home exercise program. The exercises included ankle pumps, quadriceps setting, short arc quadriceps strengthening from 45° to 0°, and heel slides.

11. During a busy morning in a hospital, you were working with a patient who told you that she was going to be discharged and wanted home health services, primarily physical therapy. After writing the note and moving on to the next patient, you realize that you did not document the patient’s desire for home therapy. What should you do? How would you document this entry into the medical record. Where should this information be placed? How might this be different if you were using an EMR?

12. When handwriting information in the medical record, you realize that you made an error in documenting the patient’s AROM. It should have been 125°, not 152°. Demonstrate how to correct this mistake.

Answer 1

Upon arrival to therapy, she told that she continues home exercise program and get in and get out of bed easily.

her strength: right biceps was 3/5, right triceps was 4/5

pain scale showed is 3/10

range of motion exercises: right elbow showed 130 flexion and 10 hyperextension

knee showed 100 flexion and lacked 10 extension

The patient walked 75 feet in the hallway of the hospital alone with the therapist who supports her lightly to maintain balance.she used a front -wheeled walker. she propelled walker outside on the sidewalk, for going up and down several ramps with verbal information on trunk positioning by me . she was able to put ankle foot orthosis after removing it self and able to check for any skin irritation independently. i performed dorsal aspect of the patinet right foot used 3MH2 at 50% duty cycle with the intensity set at 1.0 w/cm2. she performed her home exercise program namely ankle pumps, quadriceps setting, short arc quadriceps strenthening 45 to 0 , and heel slides for 10 times as per my instruction.

11.health provider must record his notes at the end of chart and write like late note visit on date of health education and information should be written. same like in medical records, mistaken entries are corrected by computreized patient record system. the mistaken entries are changed by selecting action button and add addendum.health providers would correct mistake by using addendum to the note. if date and time cannot be changed, contact informational technology staff for help.

12. if you have written information wrongly, strike with pen once and under that put your signature and get also countersigned from another staff. next to that the information should be written accurately.