Functional Reassessment

Also called a 30-Day Reassessment

This is much the same as a normal routine visit except you need to summarize what has happened during the last 30 days. Pretty easy to do.

It will appear as a PT10. Be sure to Remember to click the drop down and check 30 Day Reassessment Visit as you enter the visit. This resets the clock.

  1. The Therapy Assess/Plan section is where you summarize the progress or the decline.
  2. I start with a statement like this: This is a 30-day reassessment visit and the patient has improved/declined in the following areas:
  3. Then, I pick 2-3 objective measurements that I can show progress or decline on. Find them at:
  • Therapy Goals/Status section. Look at one like Balance, which is the TUG test score. Do a long-hold on TUG and click on history. See what the score was 30 days ago and remember that.
  • Go back to Therapy Assess/Plan and add: TUG has improved from ____ seconds to ____ seconds using FWW. If it declined add a line that may suggest a reason why they did not do as well: pain, poor sleep, dizziness, etcA finished Assessment and Plan might look something like this:

Assessment: This is a 30-day reassessment visit and the patient has improved/declined in the following areas: TUG improved from 60 seconds to 30 seconds with FWW. The 30-second sit to stand declined from 6 repetitions to 3 repetitions possibly due to arthritic exacerbation in left hip. Gait, with single effort, improved from 75 feet to 100 feet. Patient requires verbal cues for proper sit to stand hand and foot placement and requires min assist while moving from sitting to standing indicating that his hip and knee extensor muscles require more strengthening. Verbal cues are also required during gait training to encourage him to advance his foot forward and outward to avoid cross adduction or scissor gait. I checked the length of his hip adductors and did not observe hypertension or restriction in hip abduction range of motion.

Plan: (for next visit) Strengthen hip and knee extensors with BLE PNF and or progressive sit to stands. Review proper hand and foot placement for moving from sitting to standing. Give verbal cues for proper swing through foot placement to avoid cross adduction. (Hint: Write this Plan as though you are writing to an assistant to let them know exactly what you want to accomplish on the next visit.

These two sections are the A and the P of your SOAP Note.

How I Got My Life Back

How I Got My Life Back

I work for Encompass Home Health as a physical therapist. We enter our documentation on our electronic tablet devices. I developed a habit of not finishing the documentation in the home. This meant I had lots of homework to do into the late nights and early mornings. I bordered on burn-out or even worse because I was eating, sleeping and drinking my job and I did not have a life or any time for anything but work. I was so frustrated and tired of it. I remember crying out, “Lord Jesus, I need help.” THEN… Continue reading “How I Got My Life Back”

NO Homework

As of 7-21-17

Are you are tired, frustrated and approaching “Burn-Out” because you have so much documentation to finish at home? Does it feel like you don’t have a life outside of work? Well, I know exactly how you feel because I felt the same way and I almost gave up. I did documentation at night until I couldn’t think straight and started again early the next morning or even sometimes a couple of days later. Then I found a way to Get My Life Back! Continue reading “NO Homework”

Let Not Your Heart Be Troubled

Right now, the world is a scary place. With Nuclear threats from North Korea looming it is hard to know what will happen next. The news is filled with threats that can consume our thoughts and attention and may even keep us awake. One of the three components of True Health is Peace of Mind. The Good News is… Peace of Mind can be attained. Continue reading “Let Not Your Heart Be Troubled”

Systemic Inflammation and Disease

Chronic or Systemic Inflammation has been linked with numerous conditions like: Heart Disease,  Diabetes, Lung Issues (COPD, Chronic Bronchitis, and Infections), Depression, Cancer and Anger Disorders. The following video will show you how you can have a fighting chance against these enemies of our bodies. Continue reading “Systemic Inflammation and Disease”

Dehydration- An enemy of Optimal Physical and Mental Performance

Did you know that reducing water in the body as little as 5% can result in as much as a 20-30% drop in your physical performance. 10% reduction can make you sick. 20% can mean death. 1-2% reduction in the brain can mean problems concentrating and thinking? Continue reading “Dehydration- An enemy of Optimal Physical and Mental Performance”

Vertigo- One of its causes has a simple cure

Do you suffer from dizziness or vertigo. Do you feel dizzy when you move your head quickly, or does the room seem to spin whenever you lie down, roll over or get out of bed? If you experience these symptoms, you might be among a small percentage of people who have a condition called… Continue reading “Vertigo- One of its causes has a simple cure”

The Chemistry of Success

Acidity and alkalinity are at opposite ends of the pH scale. Everything we eat or drink makes our bodies more acidic or more alkaline. Dr. Susan Lark, M.D. in her book The Chemistry of Success states “The ability to maintain acid / alkaline balance has an amazing effect on six of the eight peak-performance traits.” This list will shock you… Continue reading “The Chemistry of Success”

Low Back Pain with Balance Problems

Did you fall recently? Do you have low back pain? Do you sometimes feel that you are walking on an uneven surface even though the floor is level? Do you sometimes misjudge distance while walking into another room and bump your shoulder on the door jam? Do you get very fatigued or even exhausted much earlier in the day? You might be suffering from a condition known as an….. Continue reading “Low Back Pain with Balance Problems”

The 4 Disciplines of Execution: Achieving Your Wildly Important Goals

The day I learned about The 4 Disciplines of Execution: Achieving Your Wildly Important Goals

As a physical therapist I recently attended the “Foundations Course” at the “Home Office” of Encompass Home Health in Dallas Texas. April Anthony, the CEO, spoke to the class one of the days and she inspired us with how she rose to the top in the Home Health industry by applying concepts taught in The 4 Disciplines of Execution: Achieving Your Wildly Important Goals, By Sean Covey and Chris McChesney. Little did I know was that by applying only one of the 4 disciplines my life would drastically change for the better. Continue reading “The 4 Disciplines of Execution: Achieving Your Wildly Important Goals”