Verbal cues were provided to improve postural alignment and engage in pursed lipped breathing to maximize functional tolerance. Integumentary: Surgical incision noted along midline of left knee. As clinicians, we provided skilled services, and the proof of those skilled services is clinical documentation. Compensatory Strategies Therapist Signature: ______________ Date: ____________ Time: _________, Physician Signature: ______________ Date: ____________ Time: _________, Pain/Location: 0/10; Patient states, I no longer need to use the cane and have been able to navigate up and down my steps 8 times a day. Verbal/visual/tactile cues for increased recall, problem solving, sequencing or overall technique. Use of this and other APTA websites constitutes acceptance of our Terms & Conditions. We also provide you with an option to download done-for-you templates for documentation. In supine, patient instructed in R hip abd/add, flex/ext, bridging 310 with tactile guiding due to weakness. The moment the patient can: a) Complete exercises / treatment safely and effectively on their own and PT ceased task to reduce and direct program toward pain management. See more onMedicare payment for home health. It is not necessary to establish rehabilitation or restorative therapy prior to the maintenance program, as long as the documentation justifies the need for skilled therapy to maintain function, or prevent or slow deterioration. Physical Therapy Evaluation Example Evaluation Date: 01/06/2016 Treatment Time: 09:00 to 10:00 Patient Name: Henry Smith DOB: 3/22/1957 Physician: Dr. James Anderson Medical Diagnosis: M17.12 Left knee OA s/p TKA 12/28/15 % The fear is What if I dont document correctly?. The Physical Therapy (PT) daily note read: "AAROMEs of B LE x 20reps x 3 sets to improve strength and mobility of B LE. Mild to moderate edema noted at knee with pitting noted as 1+ at tibia. Skilled Therapy Documentation: Maintenance - HomeCEUConnection stream N - Narrate your client's accomplishments. Patient instructed in the following exercises to increase RUE ROM, decrease stiffness and reduce pain level: pulleys 1-2 minutes x 3 trials to increase shoulder flexion with short rest in between trials. 1. Follow these steps to produce thorough, effective SOAP notes for physical therapy: 1. maintenance therapy under the Medicare home health benefit in accordance with individual state practice .
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maintenance physical therapy documentation examples