Nursing Service
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CURRENT STATUS (Subjective, Objective, Assessment) Frequency / Duration Pain: □ None □ Improved □ Worse Location(s) Duration Intensity 0-10 Relief Measures SUPERVISION: □PTA □OTA □HHA □POC BEING FOLLOWED □POC REVISED □PATIENT SATISFIED WITH SERVICE SKILLED SERVICES PROVIDED Home Exercise Program- DME/Orthotics /Prosthetics Instruction/Progression Assessment/Training/Modification Motor Planning Activities Strengthening Exercises ROM/Stretching Exercises Manual Techniques Neuro-Muscular Re-education Gross Motor Skills Training Positioning Activities Balance/Coordination Ex/Training Transfer Training Gait Training Postural Control Training Other: Speech Exercises Fine Motor Skills Training Language Exercises Swallowing Training Oral Motor Exercises Wheelchair Mobility Training Environmental Mobility Training Pre-Writing Training ADL Training Cognitive Skills Development Sensory Motor Activities PLANS / RECOMMENDATIONS □ Continue: □ Change: □ Contact: □ Instruction: NOTE TO PARENT/CAREGIVER: Patient/Caregiver response to teaching: Assistant Sign/Lic : Therapist Sign/Lic : Patient / Caregiver Signature X Visit Date: Time In: Time Out: N: Nursing Updated Forms 2016 Therapy Therapy Progress Note 2016 NLv3.docx.
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