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HAY 527 – Principles of Inpatient Care Documentation Practice – Initial Evaluation Notes The History of Present Illness (HPI) written by a Physical Therapist is a brief narrative summarizing the reasons for patient admission. It includes the chief complaint, diagnosis and/or differential diagnosis. There is no set method or definition of what is contained in the HPI. However, it is a short and concise summary statement usually limited to 2-3 sentences. It may be longer depending on the complexity of the patient’s medical status. Only the details most relevant to that status are included. Items are arranged chronologically. Abbreviated writing with approved acronyms, often specific to an institution, should be used whenever possible. WB status?? 1. Begin with information identifying the patient. (Age, gender) 2. Summarize the reason for admission: chief complaint or details of incident. 3. Include relevant tests and interventions related to chief complaint or status. 4. Include relevant dates pertaining to admission, transfer, events leading to injury. 5. Include recent relevant medical history. Other past medical history (PMH) belongs in that section versus in the HPI. Examples: “Pt. is a 65 year old female with c/o HA, nausea and left facial and UE tingling and weakness. CT: + right CVA” “Pt. is 45 year old male s/p MCA vs tree BIBA. + head trauma and left LE trauma found to have right frontal TBI and left hip fx. Now s/p left hip ORIF.” “Pt. is a 50 year old male p/w left ankle pain s/p fall from roof. X-ray L LE + bimalleolar fx. Ankle casted.” Case 1 – Mrs. White Adapted from Kettenbach G. Writing SOAP Notes, 3rd Ed. Philadelphia, PA: F.A. Davis Company, 2004. From the Chart: · Diagnosis is fractured right femoral neck on 1/12/02. A right hip prosthesis was inserted on 1/13/14. Patient is 65 years old. The patient is female. Physician is Dr. Sosome. HgB was 11 this morning. You are seeing the patient on 1/15/14. You tried to see the patient on 1/14/14 but patient was dizzy lying in bed and HgB was 7. Patient received blood transfusion on 1/14/14. From the Patient: · Pain R hip while standing 8/10, while lying (before ambulation) 4/10 · No PT or OT before—no walker or cane before this admission—no tub chair or portable commode currently available at home—no other assistive devices used for dressing, bathing, ambulating · Fell at home and hit R hip on side of bathtub · Live alone—senior apartment building—elevator —curbs only

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Apartment bathroom has a bathtub with a shower and shower curtain Retired this year —was a teacher —still volunteers at elementary school 3 days per week, reading with small children For recreation, patient watches her grandchildren and plays cards with friends. Watches toddleraged grandchildren once per week and plays cards with friends 2 nights per week Would like to return to her apartment after discharge Would like to eventually ambulate independently s device once again Walks approximately 2 miles 3 times per week Does not drink alcohol and does not smoke

Systems Review: · Blood pressure was 140/80 · Initially pulse rate was 80 · Respiratory rate was 12 · Neuromuscular system: gait impaired, locomotion impaired, balance impaired in standing and during ambulation, motor function impaired · Integumentary system: impaired at site; otherwise WNL · Musculoskeletal system: gross strength impaired on the right as is the range of motion · Communication is unimpaired · Affect: the patient’s emotional/behavioral responses are unimpaired · Cognition: oriented to person, place, and time; unimpaired · Learning barriers: patient wears glasses and cannot read without them—therefore, will need them for the home exercise program · Learning style—likes to be shown by the therapist and then tries to imitate therapist’s actions— visual learner · Education needs—needs to learn how to use a walker on level surfaces and on curbs, needs to learn transfers, needs to learn to check for proper healing of wound, needs a home exercise program PT Examination Performed: · UEs—ROM WNL except -5 degrees of right elbow extension · UEs—strength 4+/5 throughout (group muscle test) · ROM in left leg WNL · RLE—ROM limited secondary to post-op restrictions to 90 degrees hip flexion, 0 degrees medial rotation, 0 degrees adduction · LLE—strength 4+/5 throughout (group muscle test) · RLE—strength at least 3/5 throughout—not further examined due to recent surgery · Transfers o w/c to and from bed c moderate of 1 person o sit to and from stand with minimal of 1 person o supine to and from sit with moderate of 1 person · ambulated—parallel bars minimal of 1 approximately 20 feet once 50% PWB RLE—felt dizzy and nauseated—no further examination or interventions performed this date—nurses notified · BP: 145/90 immediately after ambulation, 135/80 3 min. after ambulation · Pulse: 105 immediately after ambulation, 82 3 min. after ambulation · Breathing rate: 18 immediately after ambulation; 12 3 min. after ambulation

HPI: Pt is a 65 year old female s/p fall at home on R hip with c/o pain, nausea and dizziness with ambulation. S/p hip prosthesis following R femoral neck fx on 1/12/02 and blood tranfusion on 1/14/02. -do not need to include pain value Pt is a 65 y/o female s/p fall at home with resultant R femoral neck fx 1/12/02. Now s/p THR 1/13/02. Attempted PT IE 1/14/02, but pt with HgB of 7 and c/o dizziness in supine. PMH: none.

Case 2: Colonel Mustard Adapted from Kettenbach G. Writing SOAP Notes, 3rd Ed. Philadelphia, PA: F.A. Davis Company, 2004. From the Chart: · The medical diagnosis is degenerative joint disease R hip—total hip replacement performed on 2/17/14 · History of HTN · Takes atenolol · 65 year old male · Dr. Sienn · One prior hospitalization—for left total hip replacement 1/10/11 o would go in PMH From the Interview: · R hip pain—area of sutures—intensity of 7 when moving—intensity of 3 when sitting—intensity of 2 when lying still · Prior to adm.—intensity of pain was 9 or 10 and pain was constant · 1 step at home to get into the house—railing on R going up · Owns a 3-in-1 commode, a walker, and a cane · Previous left total hip replacement 1/10/11 -- PMH · Immediately prior to admission—no assistive device · Lives w/wife—in his own home · Retired—hobby is gardening · Plans to return home with his wife after d/c · Eventually wants to return to gardening and yard work activities · Does not recall precautions for patients with total hip replacements · Does volunteer ushering at church—also does gardening outside of the church · Right hand dominant · Does not smoke; only occasionally drinks ETOH · Tried to walk for exercise daily—only ambulated one block prior to admission; two years ago ambulated a mile or more · Rates general health as good · Has had no major life changes in the past year · Pt’s father dies of MI at age 78

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Pt’s mother died of breast cancer at age 72 Pt has no siblings

Systems Review: · Cardiovascular/pulmonary: not impaired · HR: 80 · Resp. rate: 14 · BP: 130/85 · Edema: none noted · Integumentary: impaired · Disruption: staples R hip · Continuity of skin color: WNL · Skin texture: not tested this date · Musculoskeletal: · Gross symmetry: not impaired · Gross ROM: impaired R hip and knee · Gross strength: impaired R hip and knee · Height: 6ft 0 in · Weight: 185 lbs · Neuromuscular system: · Gait: impaired · Locomotion: impaired transfers and bed mobility · Balance: impaired in standing—uses walker; not impaired in sitting · Motor function: not impaired · Communication: not impaired · Cognition: oriented x 3; not impaired · Learning barriers: wears glasses—cannot read w/o glasses · Education needs: home exercise program, precautions for patients with total hip replacement, progression of recovery process, use of walker, ADLs, including transfers · Learning style: demonstration, then trying an activity From the Tests and Measures Performed: · Sit to/from stand w/moderate of 1 · Supine to and from sit with minimal of 1 · w/c to/from mat pivot with moderate of 1 · Toilet transfers not tested this date · UE AROM WNL · UE strength 4+/5 throughout bilaterally (group muscle test) · LLE strength 4/5 throughout (individual muscle testing performed) · LLE AROM WNL throughout · RLE—strength grossly 1/5 in hip and knee musculature—ankle dorsiflexion 4+/5—ankle plantarflexion at least 2/5 but not tested further because of the restricted weight bearing status · RLE—AROM—WNL ankle—PROM 0-20 hip flexion, 0-10 hip abduction, 0 hip extension— adduction of hip, medial and lateral rotation not tested because of hip precautions and recent surgery—knee: 0-70 · Incision—R hip—10 cm long—staples intact—over greater trochanter right—healing well · Stood bedside with walker moderate of 1 for 1 minute x 2—10% PWB RLE

HPI: Pt is a 65 year old male with DJD, c/o R hip pain at rest and when moving. S/p R THR on 2/17/14. PMH: HTN, s/p left THR arthroplasty 1/10/11 Case #3: Mr. Green Adapted from Brimer MA, Moran ML. Clinical Cases in Physical Therapy, 2nd Ed. Philadelphia, PA: Butterworth Heinemann, 2004. An 18-year-old, single, unemployed African-American male sustained a spinal cord injury from a high-speed motor vehicle accident 3 weeks ago. CT scan revealed a fracture dislocation and subluxation of C6-C7. The surgical procedures involved fixation, fusion, and instrumentation. The patient also presented with an ORIF of his left olecranon fracture and scalp lacerations. The patient was transferred to an acute rehab facility 3 weeks later with an examination consistent with C7-T1 ASIA level B quadriparesis (sensory but not motor function preserved below the neurologic level). On PT examination, the patient had an unremarkable medical history. The patient had experienced two previous motor vehicle accidents, resulting in a pelvic fracture that was now healed. The patient denied any alcohol or drug abuse and was functionally independent before the latest accident. The patient has to wear an abdominal binder and Miami-J collar when out of bed, in addition to a left arm splint and bilateral pressure-relief ankle-foot orthoses (PRAFOs) and compression stockings. HISTORY: The patient lived with his parents and younger sister is a double-wide mobile home. He was WBAT on his left upper extremity and was in no acute distress. Medications included Lovenox as a DVT prophylaxis, Didronel as a prophylaxis to avoid heterotopic ossification, Senekot as a laxative, Dulcolax suppository with digital stimulation, and ibuprofen for pain relief. SYSTEMS REVIEW: The patient was alert and oriented to person, place, and time, and cognition was WNL. No clubbing, cyanosis, or edema was noted, and dorsalis pedis pulse was WNL bilaterally. No evidence of joint deformities, increased warmth, ligamentous laxity, or subluxations in the trunk or extremities was seen. The lungs were clear on auscultation and percussion in all fields bilaterally. Stage I bilateral heel pressure ulcers, as well as healing scalp lacerations, were noted. Vital signs as follows: Temp 98.1 F, HR 80, RR 20, BP 132/70 in supine. TEST AND MEASURES: Motor strength was 5/5 grossly in bilateral UEs, 2/5 in trunk musculature, and 1/5 in bilateral hip movements. There was no presence of a motor component in the knees and ankles bilaterally, yet PROM was WNL in the lower extremities. Sensation was intact to C7 bilaterally with the presence of “spotty” sensation below the level of injury. Sacral sparing was equivocal, as per physician evaluation, and proprioception was intact in the feet. FUNCTIONAL MOBILITY: The patient rolls supine to sidelying with moderate assistance and maximal verbal cues for technique. The patient performs supine to sit transitions with moderate assistance. The patient performs lateral sliding board transfer from bed to wheelchair with moderate assistance for set-up of wheelchair and minimal assistance for transfer to chair. Sitting balance at edge of bed is fair as patient requires minimal

assistance and bilateral upper extremity support to maintain sitting position. The patient can propel his wheelchair 40 feet with supervision. The patient is able to manage the parts of the wheelchair with minimal assistance. HPI: Pt is a 18 year old male s/p SCI from MVA 3 weeks ago. CT revealed +C6-C7 fx, dislocation and pt also presented with left olecranon fracture (s/p ORIF) and scalp lacerations. Pt transferred here to acute rehab with dx of C7-T1 ASIA level B quadriparesis.

PMH: MVA x 2 with pelvic fx assisted devices do not need to be in there, would be mentioned in EVAL The patient has to wear an abdominal binder and Miami-J collar when out of bed, in addition to a left arm splint and bilateral pressure-relief ankle-foot orthoses (PRAFOs) and compression stockings.

Case #4: Mrs. Peacock Adapted from Brimer MA, Moran ML. Clinical Cases in Physical Therapy, 2nd Ed. Philadelphia, PA: Butterworth Heinemann, 2004. HISTORY: The patient, a 72-year-old retired female, was admitted to an acute care hospital through the emergency room with left-sided weakness, headache, and nausea. She was diagnosed with evolving left cerebral vascular accident and was immediately placed on an anti-thrombolytic TPA (tissue plasminogen activator) drug. During the course of her acute-care stay, she developed warmth, pain, and swelling in her right calf. Doppler scan was positive for DVT. She was placed on bed rest for 3 days, with intravenous heparin followed by oral administration of Coumadin and TEDS (compression stockings) to be worn at all times when allowed out of bed. After an acute care stay of 3 weeks, the patient was transferred to a subacute rehab facility. On admission to the rehab facility, the patient was 5 feet 2 inches tall and weighed 200 pounds. She reported a sedentary lifestyle, with hobbies of knitting and doing crossword puzzles. She was of Polish descent and liked to prepare and eat ethnic specialty foods, such as kielbasa, pierogies, and potato pancakes. She had smoked for 40 years but quit 10 years earlier secondary to problems with asthma. She resided in a two-story house that had 12 stairs with two railings between the first and second floors and three stairs with two railings to enter the home from outside. She lived with her husband of 50 years and before admission was independent in all activities of daily living and instrumental activities of daily living. The patient’s past medical history included hypertension, diabetes mellitus (adult onset), asthma, degenerative joint disease, hypercholesterolemia, and osteoporosis with a history of compression fracture of T8. Her medications included lisinpril (Zestril) 20 mg twice a day for hypertension, glyburide (DiaBeta) 5 mg four times a day for diabetes, albuterol (Proventil) 2 puffs twice a day for asthma, celecoxib (Celebrex) 20 mg/day for degenerative joint disease, and atorvastatin (Lipitor) 10 mg/day for cholesterolemia. REVIEW OF SYSTEMS: · Vital signs: BP 130/84, HR 76, RR 18

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ROM/joint mobility: Flaccid RUE, spastic RLE Gait, locomotion, balance: Bed mobility, moderate assistance of 1 to roll right to left; transfers, supinesit moderate assistance of 1; sit↔stand, maximum assistance of 1; stand pivot maximum assistance of 1; gait, non-ambulatory at the time. · Reflexes: Positive Babinski’s sing and clonus in the RLE · Balance: Sitting balance unsupported fair minus · Communication: Global aphasia TESTS AND MEASURES · MRI was positive for left CVA · Doppler study was positive for previous DVT, now resolved EVALUATION: The patient was alert and oriented to person and place but demonstrated difficulty with time accuracy. She presented with global aphasia, allowing her to respond to yes/no questions correctly approximately 40% of the time.

HPI: Pt is a 75 year old female admitted with c/o left sided weakness, H/A, global aphasia and nausea. +MRI for L CVA and +Doppler for DVT in RLE that is now resolved. Pt transferred to subacute rehab following 3 weeks of bed rest in acute care setting. PMH: HTN, AODM, hypercholesterolemia asthma, DJD, osteoporosis (OP), T8 compression fx, obesity BONUS---Write your daily SOAP note for this PT session. Be sure to include your response to the below situation. One week after admission to the rehab facility, while lying on the mat table, the patient began to exhibit signs of anxiety, including rapid breathing, sweating, and rapid extraneous hand movements including holding her chest. She was unable to verbalize her complaints and her response to yes/no questions was more inconsistent than usual. Vital signs were measures and found to be BP 100/50, HR 100 and weak, RR 24 and labored....