Soap Note

Pt. is an 83yo female admitted to hospital 10 days ago with dx of Bronchial Pneumonia. Admitted to SNF 2 days ago with balance and strength deficits. Pt. lives alone in a first floor apartment with 2 steps to enter with bilateral rails, and was relatively healthy prior to hospital stay. Pt. still drives and has a daughter who lives in the area. S. Pt. states ”I feel pretty good but am unsteady when I sit up in bed and try to walk” O.

Pt. seen for 30 min tx on this date w/ focus on static and dynamic balance training.

Pt. required CGA for sit to stand from w/c level. Pt. tolerating static standing for 5 minutes with SBA. Dynamic standing balance included weight shifting while reaching for cones, and balloon tapping and bean bag tossing, requiring Min A for standing safety for 2 minutes. Pt. also participated in lunges x10 at walker level, and resistive exercises in standing using red theraband 10 reps x2sets.

Pt. educated on breathing techniques and required moderate rest breaks. POX >96% on room air during PT session.

A. Pt. making steady progress with standing balance, with decrease tactile and verbal cues and increased standing tolerance and safety. Pt. able to compensate for loss of balance, by using Wwalker and a wide base of support. Pt. demo good understanding of energy conservation & breathing techniques, with decreased Shortness of breath during functional tasks. P. Advance to gait training next PT session. Increase standing tolerance and resistance during standing balance training per POC as tolerated.