Objective treatmentsAnalysis notes

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Right hemiplegia with increased tone

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Right hemiplegia with low tone

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Left hemiplegia increased tone

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Left Hemiplegia with low tone

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Poor sitting balance

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Reduced proprioception

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Reduced sensation

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Reduced range of movement

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Shoulder subluxation

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Shoulder pain

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Elbow contracture

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Wrist contracture

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Hand flexion contracture

(Will need more graphics here for wrist splints)

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Hip contracture

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Knee contracture

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Ankle contracture

(Will need graphic here with an ankle splint, in fact can use the one in SCI module)

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Poor rolling ability

(Will need graphic here with an ankle splint, in fact can use the one in SCI module)

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Poor pelvic tilting

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A.O.1 Bed Transfers

(Will need to do new graphics here with patient being helping from bed, likely can take from SCI module but will have a look and see if appropriate)

(holding)
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A.O.2 Bed Transfers

(Will need to do new graphics here with patient being helping from bed, likely can take from SCI module but will have a look and see if appropriate)

(holding)
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A.O.1 Sit to stand

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A.O.2 Sit to stand

(New graphics needed here, same as A.O.1 but with two therapists)

(holding)
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Standing hoists

(Need new graphic with a hoist – will source as it will need to be a very basic one, and need one of a standing frame.)

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Poor standing balance

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Supervised mobility

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Wheelchair for mobility

(Graphic here of a basic wheelchair, maybe can take from SCI)

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Poor stepping ability

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Notes

What did you discover?

This is potentially the most important legal note because this is the therapists professional opinion in light of subjective and objective findings. It should explain the reasoning behind all decisions taken and clarify and support the analytical thinking behind the problem-solving process. How you arrived at the stated goals should be indicated, as well as any factors that may require modification, such as frequency, duration or intervention itself. Adverse, as well as positive responses should be documented.

Common errors:
add

Essentially:

  • document the diagnosis you arrived at
  • include causes of the diagnosis
  • Red flag anything to be aware of (we need to treat patient holistically) note any inconsistencies