Daily Note

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   Our user asked: "I am a PT working on an acute rehab unit. We currently do narrative daily notes, and I am trying to create an easier/quicker form to document on which would capture all essential information. Any ideas?"

Ask a PT Response: "I know alot of organizations are moving towards an electronic medical record system. I have seen Centricity being used at two large hospitals. http://www.centricityusers.com/ . This program seems to work fine for documentation of inpatient records but is not as efficient for outpatient services. 

As far as coming up with a form, perhaps you could use check boxes and incorporate sections for the various parts of a progress note to be filled in. A simplified form which you just fill out sections and check boxes may be a lot quicker than narrative notes. You can make it as detailed or as general as you would want it. Below is something quick I came up with. 

S: pain (0-10/10) pre__ post__ etc....... 
O: Transfers: sit to stand __ min A __mod A __ max A __CGA __SBA __Ind 
stand to sit __ min A __mod A __ max A __CGA __SBA __Ind 
Bed Mobility: sup to sit __ min A __mod A __ max A __CGA __SBA __Ind 
sit to sup __ min A __mod A __ max A __CGA __SBA __Ind 
Gait: 
Assitive Device __Walker __W/W __cane __crutches __HHA __None 
Weight Bearing __NWB __TTWB __PWB __FWB 
ROM: 
Strengh: 
Balance: 
Other: 
A: 
P: Con't with POC ___ Comments: 
Discharge from PT ___ Comments: 

I hope this helps. Thanks for using CyberPT."

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Ask a PT Members Profile Send Private Message Find Members Posts Add to Buddy List Senior Member Joined: Jul 07 2008 Status: Offline Points: 954	Post Options Post Reply Quote Ask a PT Report Post Thanks(0) Quote Reply Topic: Daily Note Posted: Jul 08 2008 at 12:35am
	Our user asked: "I am a PT working on an acute rehab unit. We currently do narrative daily notes, and I am trying to create an easier/quicker form to document on which would capture all essential information. Any ideas?" Ask a PT Response: "I know alot of organizations are moving towards an electronic medical record system. I have seen Centricity being used at two large hospitals. http://www.centricityusers.com/ . This program seems to work fine for documentation of inpatient records but is not as efficient for outpatient services. As far as coming up with a form, perhaps you could use check boxes and incorporate sections for the various parts of a progress note to be filled in. A simplified form which you just fill out sections and check boxes may be a lot quicker than narrative notes. You can make it as detailed or as general as you would want it. Below is something quick I came up with. S: pain (0-10/10) pre__ post__ etc....... O: Transfers: sit to stand __ min A __mod A __ max A __CGA __SBA __Ind stand to sit __ min A __mod A __ max A __CGA __SBA __Ind Bed Mobility: sup to sit __ min A __mod A __ max A __CGA __SBA __Ind sit to sup __ min A __mod A __ max A __CGA __SBA __Ind Gait: Assitive Device __Walker __W/W __cane __crutches __HHA __None Weight Bearing __NWB __TTWB __PWB __FWB ROM: Strengh: Balance: Other: A: P: Con't with POC ___ Comments: Discharge from PT ___ Comments: I hope this helps. Thanks for using CyberPT."

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