HTML Preview Nursing Service page number 1.
Professional Nursing Service
THERAPY TREATMENT PROGRESS NOTE PT OT ST
N:\Nursing\Updated Forms\2016 Therapy\Therapy Progress Note 2016 NLv3.docx
Payor Source __________________________ UHHC# ______________________ Patient Identifiers: □ Facial Recognition □ Patient Address □ DOB Initial Visit
Patient Name _______________________________________________________________________ D.O.B. _________________________
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
PLANS / RECOMMENDATIONS
Assistant Sign/Lic#:
Patient / Caregiver Signature
X
Therapist Sign/Lic#:
Visit Date: _______________ Time In: ____________ Time Out: ____________
Home Exercise Program-
Instruction/Progression
DME/Orthotics /Prosthetics
Assessment/Training/Modification
Speech Exercises
Fine Motor Skills Training
Motor Planning Activities
Positioning Activities
Language Exercises
Pre-Writing Training
Strengthening Exercises
Balance/Coordination Ex/Training
Swallowing Training
ADL Training
ROM/Stretching Exercises
Transfer Training
Oral Motor Exercises
Cognitive Skills Development
Manual Techniques
Gait Training
Wheelchair Mobility Training
Sensory Motor Activities
Neuro-Muscular Re-education
Postural Control Training
Environmental Mobility Training
Gross Motor Skills Training
Other:
□ Continue:
□ Change:
□ Contact:
□ Instruction:
NOTE TO PARENT/CAREGIVER:
Patient/Caregiver response to teaching: