Hindrances to Rate of Recovery Needs to Be Documented Often

DOES YOUR PATIENT HAVE A HINDRANCE TO RATE OF RECOVERY? WHAT IS IT? WHAT ARE YOU DOING ABOUT IT? DOCUMENT IT!!!

One of the best ways to document the need for skilled care is to document all your patients hindrances to recovery and what you are doing to address it.

I have been seeing this patient for awhile and we have been working on ambulation. Progress has been slow but she still requires the skill of a PT.

The hindrance to rate of recovery that I addressed today was her lower extremity swelling.

I documented increased swelling B/L LE’s and that causing increased pain in her feet from her shoes being too tight.

To work on this I changed the patient’s shoes and educated the caregiver about the importance of well fitting shoes.

I also talked to nursing (if you are in a home it can be a child or POA) about my concern and what they are doing to address it such as how the patient has been evaluated by the doctor and medical intervention is being done to address this.

I documented that we ambulated decreased distance today because of the edema and pain and how I educated the caregivers on making sure the patient does ambulate but also when she needs rest.

I showed the caregiver exercises to do with the patient to work on the swelling.

All of this documentation shows skill. I documented a hindrance that is affecting speed of recovery (lower extremity swelling.) I documented what I did to address it such as shorter ambulation distance, change of shoes and caregiver education. I also documented vitals and talking with nursing since swelling is obviously a sign of other issues.

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