Sample Report: Pain Management Initial Evaluation/Physical Therapy Final Evaluation

 Primary Diagnosis: Right basal ganglia, temporal lobe infarct.

Treatment Diagnosis: Decreased functional mobility, inability to ambulate.

Treatment Received Today: Functional training, sit to stand with left AFO with minimal assistance for left knee extension, hip extension, transfer training, wheelchair to mat, mat to stand, gait training. Patient ambulated 150 feet with minimal assistance from her mother with left AFO and knee immobilizer. Patient was safe ambulating with mother. Patient's mother was also able to don the knee immobilizer properly. Patient has received quad cane from case manager. Patient has an orthotic order for a knee immobilizer for her left lower extremity, which she should receive shortly.

Assessment: Patient has met her goal of ambulating with minimal assistance for 150 feet with left ankle-foot orthosis, knee immobilizer, and large base quad cane with aid from mother. Patient continues to need contact guard assistance/standby assistance for sit to stand from wheelchair and wheelchair to mat transfers, secondary to decreased safety awareness and impulsivity. Patient and her mother understand home exercise plan and perform properly. Patient and her mother are encouraged to continue home exercise plane and ambulation at home. Patient will be discharged from outpatient physical therapy at this time secondary to meeting long-term goal of ambulation with plateau in progression.