[DRILL] Concise Documentation and Use of Abbreviations

1. Patient underwent a procedure called a coronary artery bypass graft on

3/17/14.

1. Pt. underwent CABG 3/17/14; or Pt. s/p CABG 3/17/14.

2. Therapist will coordinate practice of activities of daily living training

with occupational therapist and with nursing staff.

2. PT to coordinate ADL trng OT and RN staff.

3. The patient's heart rate changed from 90 to 120 beats per minute after 3

minutes of walking at a comfortable speed.

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

4. The patient's obstetric/gynecologic doctor reported that this patient has

been experiencing low back pain throughout her pregnancy.

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

5. Patient's daughter reports that patient has had a recent decrease in her

functional abilities and has a history of falls.

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

6. The patient's breath sounds were decreased bilaterally. The patient was

instructed in performing deep breathing exercises twice per day.

6. BS ↓ B. Pt. instructed in DBE b.i.d.

7. Patient's wife reports that the patient has had a history of chronic low

back pain for the past 15 years.

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

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

cane.

8. Pt.'s LTG is to walk using only str cane; or Pt.'s LTG is to amb. using only str cane.

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

9. DTR R biceps 2+.

10. Patient can ascend and descend one flight of stairs independently,

using one hand on railing.

10. Pt. can ↑↓ 1 flight of stairs I, 1 hand on railing.

383

11. Prescription received for physical therapy to include therapeutic

exercise and gait training.

11. Rx received for PT: ther ex and gait trng.

12. Resident is 82 years old and has a primary medical diagnosis of

congestive heart failure.

12. 82 y.o. 1° med dx of CHF.

13. Electrocardiogram revealed ventricular tachycardia.

13. ECG revealed Vtach.

14. Patient suffered a cerebrovascular accident, with resultant hemiplegia

of the right upper and lower extremity.

14. Pt. s/p CVA hemiplegia R UE & LE.

15. 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 supine.

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