Rehab Functional Status Medical Transcription Samples

FUNCTIONAL STATUS:  The patient required moderate assistance for bed mobility and transfers. The patient required minimal transfers in the bathroom however. The patient required moderate assistance for ambulation up to about 20 to 30 feet with a front-wheel walker. The patient requires supervision for sitting and minimal assistance for standing balance. The patient was not able to perform stair activities. The patient was maintained on toe-touch weightbearing status, which limited his mobility quite a bit. The patient is at modified independence level for upper body dressing, independent with grooming. The patient required supervision for eating. The patient required moderate assistance for lower body dressing and was dependent for toileting. The patient was incontinent of bowel and bladder. As noted, the patient had cognitive deficit, requiring moderate assistance for comprehension, expression, problem solving, and memory. Again, the patient was very cooperative and did his best to participate in the rehab program.

FUNCTIONAL STATUS:  The patient is at minimal assistance to standby assistance level for bed mobility and standby assistance for functional transfers, except for tub transfers, which required moderate assistance. The patient required standby assistance for ambulation up to 100 feet with the front-wheel walker. The patient is at modified independence level for eating, grooming, and upper body dressing; minimal assistance for lower body dressing, bathing, and toileting. The patient was continent of bowel with occasional urinary incontinence. Discharge planning was done. Family opted to place the patient at skilled nursing facility for the time being.

FUNCTIONAL STATUS:  The patient is independent with bed mobility, modified independence level for functional transfers, although the patient was unsafe and required supervision for that purpose. The patient was able to ambulate up to 300 feet with a front-wheel walker at supervision level. The patient is at supervised level for all self-care activities, except for eating, which she was independent. The patient required contact guard assistance for bathroom transfers due to decreased safety awareness. The patient had significant impairment of her cognition, requiring total assistance for problem solving, moderate assistance for memory, and maximal assistance for comprehension.

FUNCTIONAL STATUS:  The patient is at a supervised level for self-care activities including eating, upper body dressing, lower body dressing, and toileting. The patient requires minimal assistance to supervision for bathing. The patient is at supervised level for functional transfers including bathroom transfers. The patient is able to ambulate up to 200 feet with a front-wheel walker requiring supervision. The patient required contact guard assistance for supervision. The patient required minimal assistance for wheelchair activities. The patient was incontinent of bladder and continent of bowel for the most part, but again, the patient has some difficulties at nighttime due to cognitive deficit. Cognitively, the patient required total assistance for auditory comprehension and maximal assistance for visual comprehension. Expression was also quite limited, although the patient had good spontaneous speech. The patient required maximal assistance for problem solving and social interaction and total assistance for memory. The patient has a very poor memory. The patient had decreased safety awareness, and the patient will require 24-hour supervision. The family was informed about that and was trained on that.

FUNCTIONAL STATUS:  The patient is at modified independence level for functional mobility including transfers and also ambulation up to 150 feet with a front-wheel walker. Range of motion of the knee is actively 6 to 80 degrees and passively 4 to 86 degrees. The patient was continent of bowel and bladder. The patient is at modified independence level for all self-care activities including toileting and lower body dressing.

FUNCTIONAL STATUS:  The patient did not receive significant amount of therapy, but the patient was at minimal assistance for transfer and was able to ambulate about 100 feet with minimal assistance with hand-held assistance. The patient is at minimal assistance level for self-care activities. As mentioned, comprehensive evaluation was not feasible due to discharge against medical advice. It appears the patient was overall continent of bowel and bladder.

FUNCTIONAL STATUS:  The patient was independent with bed mobility and modified independence level for ambulation greater than 150 feet with a front-wheel walker. The patient is at modified independence level for wheelchair mobility and transfers. The patient requires supervision for stairs and curbs. The patient is independent with grooming and upper body dressing and modified independence level for eating. The patient is at modified independence level for toileting. The patient did not have any incontinence of bowel and bladder at the time of discharge.

FUNCTIONAL STATUS:  The patient is at standby assistance level for bed mobility and transfers. The patient is at standby assistance for ambulation with front-wheel walker up to 50 feet. The patient’s limitation was deconditioning and also the osteoarthritis and pain. The patient required contact guard assistance for lower body dressing, toileting, and minimal assistance for bathing. The patient was at modified independence level for eating and supervision for grooming, upper body dressing. The patient was able to negotiate curbs with contact guard assistance with a walker. Overall, the patient was continent of bowel and bladder. Family training was done.

FUNCTIONAL STATUS:  The patient is at supervised level for bed mobility and modified independence for all transfers. The patient, however, required minimal assistance for tub transfer bench transfers. The patient required contact guard assistance/supervision for ambulation with a front-wheel walker up to 150 feet. The patient is supervised level for eating; modified independence level for grooming, upper body dressing, and lower body dressing; minimal assistance for bathing. The patient is continent of bowel and bladder. Cognitively, the patient was normal and swallow was normal. Family training was done with the spouse.