Tip of the week: Determining prior and current functional status
Rehab Regs, October 3, 2008
Ask patients specific questions regarding what they could do prior to their injury or illness and what they either can’t perform or are having difficulty performing since their injury or illness occurred.
Inquiries should include but are not limited to the following:
• Ambulation
• Bed mobility and transfers. Inquiries regarding bed mobility and transfers should include:
-Whether physical assistance is required
-What type of transfer performed (e.g., tub, toilet, sit to stand, bed to wheelchair)
-What type of assistive device is utilized to complete transfer
-Verbal cues
• Dressing
• Hygiene
• ADLs. Specifically address the patient’s ability to do the following:
-Cook and prepare meals
-Complete laundry
-Complete household cleaning, including vacuuming, dusting, cleaning the bathroom, etc.
-Make a bed
-Perform other general household tasks
• Driving
• Sitting and standing tolerance
• Problem solving
• Speech/swallowing
• Employment
• Goals
This tip is from HCPro’s Pocket Guide to Therapy Documentation.
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