Think of Treatment and Documentation Like A Story

How to Make Skilled Care Easier

To make documenting skilled care easier and more efficient think of it like you are telling a story. A story that has a problem then a twist and then the result.

So for this patient her major goal is being able to ambulate without assist again.

Her biggest problem with ambulation is coordination. She is ok when ambulating on a straight path in silence but when when turning she tangles her legs up and loses her balance (she has fallen many times doing this.) And she also loses her balance during dual tasking.

So we started with ambulation and documented the skilled care required. We then focused the rest of the treatment on those deficits. Everything we did that day went back to her ambulation deficits.

And then in the assessment I summed up her deficits. Why the activities were performed. And how she responded to treatment. Also any hindrances that occurred to why she needs further work in these areas.

Some of the Activities Performed 

• Cone taps with numbers - I randomly called out different numbers and she had to tap that cone
• Marching while punching the punching bag
• Ambulating around cones
• LE stepping with opposite UE reaching

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