Patient required vc and visual demo to perform correctly. Standing: mini squats x 10, hip abduction x 10 bilaterally, hamstring curls x 15 bilaterally, step up to 3 step x 10 alternating LE. of therapy can reasonably be expected to benefit the patient. 2. Author Beth Reigart. Some examples listed on this site are: Instruct patient and caregiver in use and care of communication system. All Rights Reserved. 2023 Harmony Healthcare International, Inc.. All Rights Reserved. Skill acquired by experience, study, or observation. Driving while tired or fatigued. To help therapists and assistants improve their documentation, the following are examples of documentation that clearly demonstrates the skilled nature of therapeutic exercise. b) Work with a caregiver to achieve outcomes. Every license unlimited ongoing support (phone / email / live chat), billing software integration, unlimited appointments, unlimited documentation, unlimited document uploads and unlimited electronic faxing. This evaluation is of moderate complexity due to the changing nature of the patients presentation as well as the comorbidities and medical factors included in this evaluation. This is achieved with a combination of customized physical therapy documentation examples, specific to the patient and your treatment philosophy, regular tests, standardized tools, subjective feedback and various measures. Outlining patient progression through a series of goals that are achieved and modified is an excellent way to convey progress and justify treatment. This initial blog will focus on mode of therapy provisions under this new payment model and address the documentation guidelines regarding group and concurrent therapy. Reduced In Touch EMR is a leader in web-based EMR for our practice. 2021 PTProgress - Our content does not constitute medical, financial, or legal consultation. See privacy policy and disclosure page for details. Documentation of occupational therapy services | AOTA 5. Appropriate Use and Documentation of Therapeutic Activities (97530) Lack of proper vehicular maintenance. PT developed functional activity tolerance program and instructed patient in NuStep training to increase biofeedback to BLE, mimic reciprocal pattern and increase overall LE strength to decrease abnormal gait pattern. Patient instructed in RLE exercises to increase LE strength s/p R knee replacement. Couldnt have asked for more. Assessment Statement: Patient presents with signs and symptoms consistent with diagnosis of L knee OA, s/p 1 week post operative L TKA. Skin appears dark pink, dry and well healing. stream The patient will maintain the use of safe swallow strategies as instructed by Speech therapy at each meal to prevent aspiration.