Documenting Prior Level of Function

During the Evaluation

During an evaluation you must document your patients prior level of function.

In this documentation write how long ago the patient was at this level. I usually try for a time span of 1 year or less.

Make sure to document all areas you could be focusing on during treatments. If you are unsure for is you will be working on stairs still document prior level.

Be Specific

During transfers make sure to provide what type of transfer it was. For example sit to stand, stand pivot, squat pivot, etc.

Also for transfers document the surface such as from a toilet, recliner, bed, sofa, etc.

With ambulation make sure to write what assistive device they were using such as a rolling walker or quad cane. Include type of surface such as carpet, wood, uneven. Also include the distance and if they only ambulated that distance in the home document that or if they were going out into the community include that.

And we know documentation can be brutal

That’s why we wrote a documentation cheat sheet for you!! Make sure to check that out on our main page HERE!

Do you know other therapists that could use more ideas for client-centered treatment? Make sure to share this post and follow us and tag them on Instagram www.instagram.com/thenoteninjas

To view our favorite things that you can purchase on Amazon, CLICK HERE