Documenting Hindrances and What You Are Doing to Address Them

DOCUMENTING HINDRANCES

This patient has a significant fear of falling.

She is just starting therapy and is very hesitant to progress to more advanced balance activities secondary to fear of falling caused by a recent fall.

But that is ok as long as we address this fear and take steps to resolve it.

Throughout my notes I document her fear of falling and I document what I am doing to address it such as:

• Educating patient on fall prevention techniques
• Educating her caregiver on fall prevention strategies to implement with her
• Beginning with B/L UE support and progressing to 1 UE support or no UE support as she gained confidence
• Showing increased balance activities to improve patient's confidence in her balance.
• Encouraging her that her fear is valid but that we will work through it together
• Gaining a good relationship with her so that she trusts me and will progress activities.

I document this throughout her treatment sessions and then will document this at time of the progress note. Just make sure in the progress note you document the hindrance and what you did and that your previous treatment notes validate that you did do those interventions!

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