OBJECTIVE FINDINGS:
Observation: This patient appears a normally developed Hispanic female, her stated age. She gaits and moves normally with the exception of an antalgic gait on the right.
Palpation: Positive in the right buttocks.
Range of Motion: Forward flexion, 95 degrees with pain at the end of range. Right side bending, 30 degrees with pain at the end of range. Left side bending, within normal limits.
Extension, 0 degree with immediate pain. Painful stimuli on the right side.
Resisted Motion: Positive with left side bending.
Muscle Strength: 4/5 in the right ankle and toe, 5/5 in all other areas.
Radiculopathy: Positive with pain in the posterior leg from the buttocks to the foot and numbness in the last three toes.
Sensation: Decreased to pinprick over the right lateral calf. Lasegue’s sign positive on the right at 70 degrees. Cram test positive at the same range.

TREATMENT PLAN:  We would like to see the patient daily x10 days as prescribed for hot moist pack, ultrasound, and intermittent pelvic traction. We would also like to add exercises to the low back into extension at the appropriate interval.

Sample #2

HISTORY:  The patient is a (XX)-year-old Asian male who sustained a C4-C5 crush fracture as well as a fracture of C3 and C6. The patient states that since then he has had right-sided paralysis but has been functional. The patient states in the last six months he has noticed a decline in his function, especially in his right wrist and hand, thus prompting the patient to seek medical intervention. The patient is referred to physical therapy for right hand weakness for PT evaluation and a home program to increase strength and function of right hand and wrist.

SUBJECTIVE FINDINGS:  The patient denies any pain in the right upper extremity or right lower extremity. The patient states he is ambidextrous. The patient states his ambulation has declined as well and has noticed increase in loss of balance; although, the patient has denied any falls. The patient does not use an assistive device, nor does he use an AFO on that right ankle.

OBJECTIVE FINDINGS:  The patient ambulates with an abnormal gait pattern. The patient presented with a right toe drag, decreased right knee flexion, decreased right hip flexion, and increase in trunk swing. The cervical range of motion was within normal limits for all movements, except bilateral side bending, within functional limits. Right shoulder AROM: Flexion 0-160 degrees, abduction 0-160 degrees, external rotation 0-70 degrees, internal rotation within normal limits. Right shoulder PROM: Flexion 0-180 degrees, abduction 0-180 degrees, external rotation 0-80 degrees, and internal rotation within normal limits. Right shoulder strength: Flexion 4/5, abduction 4-/5, right biceps strength 4-/5, and triceps 3+/5. Right grip strength was 25 pounds and left grip strength was 60 pounds. Right wrist and finger range of motion: Passive range of motion within normal limits, active range of motion limited, yet functional. The patient did not present with a right hand contracture or finger contracture. Right lower extremity range of motion: Right hip not tested, is limited, although is functional. The patient is lacking active knee extension range, approximately lacking 20-30 degrees. Right ankle strength: Dorsiflexion 3-/5 and plantarflexion 5/5. Muscle tones: The patient was noted to have multiple beats of clonus in right ankle, did not test tone in upper extremity. Palpation negative.

TREATMENT PLAN:  This patient was seen for a one-time visit only for evaluation and treatment. The patient was evaluated as per above. Treatment was provided as well. The patient was given a home exercise program, including right upper extremity and lower extremity strengthening exercises, as well as stretching exercises for the right shoulder. The patient demonstrated understanding of the exercising and was able to demonstrate them accurately. The patient was also given yellow TheraBand to complete these exercises. The patient was instructed to perform these exercises one to two times daily to increase his strength and range of motion. Further physical therapy intervention is not indicated at this time, as the patient is independent with home exercise program.

The post Physical Therapy Progress Note Sample Report appeared first on Medical Transcription Sample Reports.

OBJECTIVE:
General:  The patient is a well-developed, well-nourished male, in no apparent distress.
Vital Signs:  Temperature 98.8 degrees, pulse 62, respirations 18, and blood pressure 136/58.
HEENT:  Head is normocephalic.
Neck:  Supple to palpation.
Lungs:  Clear to auscultation.
Heart:  Regular rate and rhythm with a grade 2/6 systolic ejection murmur.
Extremities:  Examination of the extremities showed good peripheral pulses and is normal in regards to color, tone, and circulation. The wound on the patient’s hip is well healed without any sign of infection or skin breakdown.

FUNCTIONAL STATUS:  Functional skills are at a supervised level with transfers and mobility skills. He is able to ambulate little greater than 250 feet with the use of a front-wheel walker. He still requires some contact guard assistance, particularly with high-level mobility skills. His self-care skills still showed some impairment with his memory; however, he does demonstrate approximately 80% accuracy. He is at a supervised level with his bathroom skills.

LABORATORY DATA:  The patient’s urine grew out Enterococcus faecalis sensitive to ciprofloxacin.

ASSESSMENT:
1.  Status post femur fracture, status post total hip replacement.
2.  Urinary tract infection, resolving.
3.  History of carcinoma of the prostate.

PLAN:  We will continue the current treatment program in preparation for discharge to home today or tomorrow depending on family support, and this will be discussed in team conference today.

SUBJECTIVE:  The patient states that he slept very well and feels quite refreshed today.

OBJECTIVE:
Vital Signs:  Temperature 97.2 degrees, pulse 66, respirations 20, and blood pressure 132/62.
HEENT:  Head is normocephalic.
Neck:  Supple to palpation.
Lungs:  Clear to auscultation.
Extremities:  The wound on the patient’s hip is well healed without any sign of infection or skin breakdown. Staples and sutures are ready for removal.

FUNCTIONAL STATUS:  Functionally, the patient is able to transfer and ambulate 100 feet x2 with the use of a front-wheel walker. He is able to begin ascending and descending steps but still is not competent at that. His sit-to-stand transfers require minimal assistance at this point. Bathroom skills are at a minimal assistance level. Staples and sutures on the patient’s leg are ready for removal and support stocking elastic band at the top appears to be too tight for the patient, and support stockings will be discontinued.

ASSESSMENT:
1.  Status post right total hip arthroplasty.
2.  Osteoarthritis of the right hip.

PLAN:  We will continue with current treatment program with plans for the patient to be discharged to home this week.

SUBJECTIVE:  The patient has no complaints. He is tolerating therapy well. He showed improved concentration, memory, and strength.

OBJECTIVE:
Vital Signs:  Temperature 98.2 degrees, pulse 90, respirations 18, and blood pressure 138/88.
HEENT:  Head is normocephalic.
Neck:  Supple to palpation.
Lungs:  Clear to auscultation.

LABORATORY DATA:  The patient’s blood sugars are still running slightly elevated.

FUNCTIONAL STATUS:  The patient shows improved balance and some passive movement is emerging from his right upper and lower extremity. Functional transfers are still at moderate assistance level, and he requires maximal assistance for lower body dressing. He is at a supervised level for upper body dressing skills. Oral motor control is still sluggish, and the patient is somewhat unsafe with his swallow, even with chin tucking technique.

ASSESSMENT:
1.  Cerebrovascular accident.
2.  Dysphagia.
3.  Dysarthria.
4.  Right hemiparesis.

PLAN:  We will continue with the current treatment program. The patient will begin training on tall kneeling techniques.

The post Rehab Progress Note Sample Report appeared first on Medical Transcription Sample Reports.

HISTORY OF PRESENT ILLNESS:  The patient is an (XX)-year-old Hispanic female who was in her usual state of fair health until MM/DD/YYYY when she sustained a fall in her home. The patient had significant pain in her left hip and was brought to the hospital where x-rays showed a subcapsular fracture of the left femur. The patient was brought to the operating theater where she underwent a left total hip arthroplasty. The patient tolerated the surgery well and postoperatively was started on physical therapy. She showed herself to be a good rehabilitation candidate and was then transferred to the rehabilitation hospital for continuation of her care.

PAST MEDICAL HISTORY:  Significant for those mentioned in the HPI plus Alzheimer’s disease, peptic ulcer disease, hypertension, osteoarthritis, hyperlipidemia, and cardiovascular disease.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY:  The patient lives with her husband in a one-story apartment. She was previously supervised with activities of daily living and mobility skills.

PHYSICAL EXAMINATION:
GENERAL:  The patient is a well-developed, elderly female in no apparent distress.
VITAL SIGNS:  Temperature 100.2 degrees, pulse 110 beats per minute, respirations are 20 breaths per minute, and blood pressure is 132/78 mmHg.
HEENT:  Examination of the head and neck is normocephalic. She has full ocular range of motion. Pupils are equal and reactive to light.
NECK:  Supple to palpation.
LUNGS:  Clear to auscultation with diminished breath sounds.
HEART:  Heart sounds S1 and S2 are present with grade 3/6 systolic ejection murmur, best heard in the left sternal border.
ABDOMEN:  The patient has normoactive bowel sounds with a soft, obese, and nontender abdomen. No organomegaly is palpated.
EXTREMITIES:  Examination of the patient’s extremities shows good peripheral pulses. The incision site is healing well without any sign of infection or skin breakdown. Staples and sutures are in place. Homans sign is absent. Tone is within normal limits in both lower extremities. Sensation is grossly intact in both lower extremities.
NEUROLOGIC:  Cognitively, the patient had some impairment with short-term memory and processing.

FUNCTIONAL EVALUATION:  The patient required moderate assistance with activities of daily living and maximal assistance with her self-care skills.

IMPRESSION:
1.  Status post left femur fracture.
2.  Left total hip arthroplasty.
3.  Obesity.
4.  Alzheimer’s disease.
5.  Peptic ulcer disease.
6.  Hypertension.
7.  Fever of unknown origin.
8.  Osteoarthritis.
9.  Cardiovascular disease.
10. Possible cellulitis.

REHABILITATION GOALS:  The goal is for the patient to be at a modified independent level with activities of daily living and mobility skills.

ESTIMATED LENGTH OF REHAB STAY:  Seven to ten days before returning to home.

REHABILITATION PLAN:  The patient is to undergo a course of physical and occupational therapy, dietary, and rehabilitation nursing with a goal of the patient being at a modified independent level with activities of daily living and mobility skills. Physical therapy will work with the patient on general mobilization skills, upper and lower body strengthening, pre-gait and gait training activities, and balance and coordination skills. Occupational therapy will work with the patient on feeding, grooming, upper and lower body dressing skills, toilet-to-tub/shower transfers with and without the use of adaptive equipment. Dietary will work with the patient on appropriate diet. Rehabilitation nursing will work with the patient on bowel and bladder management program and appropriate taking of medications. Medical will monitor the patient’s fever status and dementia and will adjust therapies and medications as needed. For possible cellulitis, we will start the patient on Levaquin. We will also perform family training while the patient is in the hospital prior to her discharge.

The post Fracture Rehabilitation History and Physical Sample Report appeared first on Medical Transcription Sample Reports.

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.

The post Rehab Functional Status Medical Transcription Samples appeared first on Medical Transcription Sample Reports.