Left neglect interferes with ability to perform basic ADLs.
Patient expressed doubts about ever getting better and then began to cry.
Mrs. Jones reports that she had no pain in her hip last night or this morning
Specific department proper names are
It is essential that you do not disclose or give out any health records or client information without fully understanding the law and knowing your facility's policies and procedures.
Do not make up your own abbreviations, and do not use any abbreviation that is not on your facility's approved list.
Peter Piper demonstrates improved activity tolerance, as evidenced by standing at the kitchen counter 3 minutes longer than yesterday before requiring rest during meal preparation activity.
“I don’t need therapy.”
The nurse reports that Mrs. Smith has been in her room crying all morning.
manual muscle test
Mrs. Jones demonstrates readiness to progress to standing with SBA while showering.
Mrs Jones will perform standing tolerance exercises while cooking breakfast in the OT Clinic next session
Veteran would benefit from further instruction to incorporate total hip precautions into lower body dressing, bathing and toileting
Child stated, "This is hard!" during a bilateral coordination exercise requiring UE strength and stability.
Continue OT one hour daily sessions for two weeks to Improve motor planning skills for dressing. By the end of the next session, veteran will demonstrate the ability to identify front and back of shirt with one verbal cue.
Use of correction fluid or correction tape in a medical record is considered an illegal alteration of the record.
"It's easier for me to get dressed now."
The following is a subjective statement that might be included in a SOAP note:
The OTA asked the patient to _____________ the scissors down on the table.
It is understood that the subjective statement in a SOAP note comes from the individual receiving the therapy unless otherwise stated
The following is a subjective statement that might be included in a SOAP note:Resident needed max assist x 2 to transfer from w/c to bed.
The client refused to _____________ the doctor's diagnosis. Fill in the blank: The client refused to _____________ the doctor's diagnosis.
A medical diagnosis for the purpose of the medical visit on the given date of the note written
the patient's Chief Complaint, or CC
information that the healthcare provider observes or measures from the patient's current presentation
The plan is what the health care provider will do to treat the patient's concerns