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Documentation Cheat Sheet

Section 1: Impairments

Section 2: Fill in the blank documentation

Section 3: Full copy and paste documentation

In order to show you skill during your documentation you need to:

  1.  Assess your patient and provide skilled cues based on their performance
  2.  Show why your skill was needed - why you had to be there and why a caregiver or other person could not be working with this patient

The documentation included below can be used for almost any activity. 

To use this cheat sheet, have your patient perform any activity such as ambulation/functional mobility, transfers, exercises, balance activities, etc. and observe how they are presenting.  From there, determine if they have any impairments from the list below and document that in your treatment note. Then go to the sections below and copy and paste any of the cues you provided into you documentation.

Our documentation samples may need to be modified.  However, they can be used as a baseline to document your skill.

Feel free to copy and paste. Don't forget to modify based on your observations and skill your provide, such as facilitating/hindering different muscle groups, changing the exercise or activity, providing a specific skilled strategy (ex. spaced retrieval or blocked practice), or changing patient presentation.

Always make sure to add in the level of assistance (CGA, SBA, minimal assist, moderate assist, maximal assist)

 

Impairments

Assess your patient during any activity and then document the impairment they are presenting with.

Some examples of impairments you may be recognizing are listed below. 

After you document the impairment, document what you did to address it.  Examples of how you can address the impairments are in the two following sections below.

Examples of some impairments you may have to cue/assist with:

  • Pain
  • Forward flexed trunk
  • Posterior or anterior pelvic tilt
  • Thoracic extension
  • Foot drop
  • Limited range of motion (ROM)
  • Decreased strength
  • Decreased fine motor coordination
  • Decreased endurance
  • Decreased O2 saturation
  • Unstable vital signs
  • Visual deficits
  • Poor head and neck control
  • Poor motor planning
  • Difficulty with sequencing
  • Lateral lean/sway
  • Forward rounded shoulders
  • Increased knee flexion in standing/stance phase
  • Decreased ability to weight shift
  • Pelvic tilt
  • Decreased wrist mobility
  • Impaired depth perception
  • Decreased peripheral vision
  • Difficulty attending to task 
  • Shoulder elevation
  • Scapula protraction
  • Lumbar extension
  • Posterior lean
  • Loss of balance
  • Decreased hip mobility
  • Poor core/trunk control
  • Decreased trunk rotation
  • Decreased proprioception
  • Decreased knee flexion in swing phase
  • Shuffling
  • Decreased step length
  • Decreased heel strike
  • Antalgic
  • Hip circumduction
  • Increased base of support (BOS)
  • Slow cadence
  • Decreased hand-eye coordination
  • Decreased dexterity
  • Lower extremity scissoring
  • Decreased upper extremity swing
  • Knee buckling
  • Hip hiking
  • Decreased weight bearing (on 1 lower extremity)
  • Poor eye gaze
  • Cognitive impairment 
  • Decreased hip flexion
  • Increased weight bearing on toes or heels
  • Hip external or internal rotation
  • Shortness of breath
  • Chest breathing
  • Decreased eccentric control
  • Decreased glute activation
  • Decreased quad activation 

Cues to Provide/Fill in the Blank Documentation

After assessing your patient and discovering one of the impairments above - what are you doing to correct or improve it?

Are you providing verbal, visual, physical or tactile cues? What are they? How many cues do they need (SBA, CG, min, mod, max)?

Examples of cues you could be providing:

Patient required ….

  • Minimal tactile cues to core to facilitate activation due to patient presenting with ____
  • Physical assist to to keep hips facing forward as patient was presenting with ____
  • Verbal cues for increasing/decreasing pace while performing ____
  • Tapping of obliques to facilitate timely contraction of muscle due to patient presenting with (impairment)
  • Physical assistance at thumb to improve pressure while performing ____
  • Cues for breathing technique to prevent Valsalva during ____
  • Tactile cues to keep the pelvis in an anterior pelvic tilt while performing ____
  • Cues to improve eccentric control of ____ muscle during ____
  • Verbal cues for correct sequencing while participating in ____
  • Verbal cues for increased safety awareness during ____
  • Physical assistance at hips while reaching forward during ____
  • Cues to increase glute activation due to patient presenting with  ____
  • Tactile cues at humeral head to increase shoulder flexion during ____
  • Verbal and tactile cues to contract the abdominal muscles and improve lumbar stability when _______
  • Verbal and tactile cues for proper spinal posture during ____
  • Education on mind muscle connection to improve neuro-re ed while performing _____
  • Physical assist to keep pelvis in neutral during ____
  • Patient requires minimal tactile cues to engage hip abductors in supporting LE to decrease lateral lean during ____
  • Progressed to _____ with tactile cues for core stability
  • Colored circle on wall for a visual cue to look straight ahead while performing ___
  • Tactile cues at thoracic spine to adjust posture during ____
  • Education on using the stepping strategy when losing balance during _____
  • Tactile cues on back for extension while performing _____
  • Tactile facilitation at DIP and PIP joints to increase flexion while picking up  ____ during ____
  • Tactile cues to hip hinge vs bending from back when performing ____
  • Visual cues for eye gaze to maintain balance during ____
  • Patients O2 taken during _____ secondary to reports fatigue at 94%.
  • Verbal cues for even weight distribution on B/L LE's due to LOB while performing ____
  • Patient required physical assist at hips for weight shifting during _____
  • Physical correction to maintain upright neutral posture as patient presents with lateral sway during _____
  • Tactile cues to decrease hip hiking during ___
  • Visual/verbal cues for proper hand placement and support for stability with ____
  • Physical assistance to increase elbow flexion while ____
  • Tactile cues to increase hip flexion ROM to decrease toe drag during ____
  • Verbal cues to increase step length during ____
  • Verbal cues to promote increased shoulder ROM during to reach towards ____
  • Verbal/visual cues for ankle, hip strategies due to LOB during ____
  • Visual cues of markers on floor for foot placement while performing ____

 

Copy and Paste Documentation - Full Documentation Examples

Examples of how to use the above impairments and cues.

You can always change an activity, such as ambulation, to a balance activity.

Copy and Paste documentation:

  • Patient ambulated with forward flexed trunk therefore minimal tactile cues provided to upper thoracic spine to promote extension.
  • Patient with difficulty weight shifting during stepping activities therefore manual assist was provided at hips to improve weight shifting to advance contralateral lower extremity.
  • Patient presents with lateral lean, requiring tactile cues to obliques to facilitate activation.
  • Patient presents with foot drop therefore provided tactile cues to facilitate increased hip flexion to clear foot.
  • Tactile cues to right hip flexor during swing phase to increase hip flexion ROM to clear foot.
  • Verbal cues for toe off as patient steps with flat foot.
  • Physical assist due to loss of balance when scissoring LE's.
  • Manual assist at hips to improve weight shifting to increase step length.
  • Visual cues with a mirror to improve posture with increased trunk and hip extension.
  • Verbal cues for increased safety awareness during meal prep. 
  •  Auditory cues with a metronome to increase cadence.
  • Tapping of right quad to facilitate contraction of muscle due to knee buckling.
  • Verbal cues for breathing technique to prevent Valsalva.
  • Tactile cues to back of shoulders to keep them back and down due to elevation and rounded forward.
  • Verbal cues for sequencing of SPC with UE swing.
  • Verbal cues to improve heel strike as patient hits ball of foot vs heel.
  • Verbal and tactile cues to contract the abdominal muscles to improve lumbar stability when adding in larger UE movements.
  • Physical assist to keep pelvis in neutral as patient hip hikes on right.
  • Manual assist to improve right knee flexion during swing phase due to hip circumduction.
  • Tactile cues to engage right hip abductors in stance LE due to Trendelenburg.
  • Visual cue of a picture in front of patient to maintain straight eye gaze.
  • Physical assistance to increase elbow flexion while threading UE through shirt. 
  • Physical assistance to increase posterior range of motion to donn belt
  • Education on using the stepping strategy when losing balance.
  • Tactile cues on thoracic spine to improve posture.
  • Verbal cues to increase UE swing and sequencing with LE's.
  • Patients O2 taken secondary to reports fatigue at 96%.
  • Patient instructed in diaphragmatic breathing to improve endurance.
  • Tactile facilitation at DIP and PIP joints to increase flexion while picking up utensil during self-feeding. 
  • Verbal cues for patient to ambulate closer to RW.
  • Verbal cues to keep step length even when approaching the chair.
  • Verbal and physical assist due to increased posterior weight distribution.