IPP - Exercise 2-2 Concise Documentation and Use of Abbreviations

Electrocardiogram revealed ventricular tachycardia.

ECG revealed v-tach

The patient's heart rate changed from 90 to 120 beats per minute after 3 minutes of walking at a comfortable speed.

Pt.'s HR △'d from 90 → 120 bpm ¯p 3 min of amb. at comfortable speed

Deep tendon reflex of right biceps was recorded as a 2+.

DTR R biceps 2+

Patient's wife reports that the patient has had a history of chronic low back pain for the past 15 years.

Pt.'s wife reports pt. has h/o chronic LBP x 15 yr.

The patient's breath sounds were decreased bilaterally. The patient was instructed in performing deep breathing exercises twice per day.

BS ↓ B. Pt. instructed in DBE b.i.d.

The home health aide was instructed in assisting patient to perform active-assistive range of motion exercises, which were straight leg raises and hip abduction in spine.

HHA instructed to assist pt. in AAROM exer: SLR and hip abd in supine

Therapist will coordinate practice of activities of daily living training with occupational therapist and with nursing staff.

PT to coordinate ADL trng ¯c OT and RN staff

Patient can ascend and descend one flight of stairs independently, using one hand on railing.

Pt. can ↑↓ 1 flight of stairs (should be circle with single I inside), 1 hand on railing

Patient suffered a cerebrovascular accident, with resultant hemiplegia of the right upper and lower extremity.

Pt. s/p CVA ¯c hemiplegia R UE & LE.

Patient underwent a procedure called a coronary artery bypass graft on 3/17/08.

Pt. underwent CABG 3/17/08; or pt. s/p CABG 3/17/08

The patient's obstetric/gynecologic doctor reported that this patient has been experiencing low back pain throughout her pregnancy.

Pt.'s OB/GYN reported pt. had LBP t/o pregnancy

Resident is 82 years old and has a primary medical diagnosis of congestive heart failure.

82 y.o. ¯c 1° med dx of CHF.

The patient's long-term goal is to be able to walk using only a straight cane.

Pt.'s LTG is to walk using only str. cane. Or, Pt.'s LTG is to amb. using only str. cane

Patient's daughter reports that patient has had a recent decrease in her functional abilities and has a history of falls.

Pt.'s daughter reports pt. has had recent ↓ in fx abilities and h/o falls

Prescription received for physical therapy to include therapeutic exercise and gait training.

Rx received for PT: ther ex and gait trng.