Daily Note
Printed From: CyberPT - Your Online Physical Therapy Resource
Category: Physical Therapy Professional Forum
Forum Name: General Discussion
Forum Description: General discussion for physical therapists, physical therapist assistants and other health care professionals.
URL: http://www.cyberpt.com/ptforum/forum_posts.asp?TID=7
Printed Date: Nov 27 2024 at 3:56pm
Software Version: Web Wiz Forums 11.03 - http://www.webwizforums.com
Topic: Daily Note
Posted By: Ask a PT
Subject: Daily Note
Date 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/ - 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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