Subjective:

- Pt. seen in SNF for self-care training in standing prior to d/c home. Pt. stated doing
“fine”, and ready for treatment. At end of treatment pt. reported feeling good.

Objective:
- Vitals signs: 144/84 85HR prior to tx, after treatment vitals are 148/95 100 HR. Pt.
required max a for w/c mobility to sink, one verbal cue for locking brakes of w/c and one
verbal cue for reaching back to chair prior to sit. Pt. attempted sit to stand 3x before
success with both hands pushing from w/c.
- Pt. used Bilateral coordination to open bag and grasp toothbrush. Pt. using R hand
dominant grasp for toothbrushing. Pt. using walker or sink with left hand for support
during standing task. Pt. observed to bear in LLE more than R for standing at sink. Pt.
able to sequence steps for face washing and toothbrushing without cues. Pt. required
CGA during standing task. Pt. able to adjust water temperature and aware of scent of
soap. Pt. able to comprehend and understand verbal instructions and respond accordingly.
Pt. demonstrated visual attention to task, spatial awareness for orientation of objects.

Assessment:
- Pt. with good bilateral coordination and sequencing of self-care grooming/hygiene. Pt.
with good hand strength for grasp. Good kinesthetic, visual, and auditory awareness. Pt.
required cues for w/c safety, impacting safety for independence with transfer/mobility. Pt.
required multiple attempts for sit-to-stand transfer and demonstrated unequal stability in
standing which may indicate limited strength, coordination and/or pain for transfers.
Vital signs indicate slight increase in HR following standing treatment which can indicate
fatigue or stress.

Plan:
- Continue to work on w/c safety. Continue to work on strengthening and balance for
sit-to-stand transfers. Continue to work on endurance/activity tolerance.