Physical Therapy Charts to Nursing Home or Home Health Health Record

Personal Health Communication, Transfer of Care, Coordination of Care.

Patient, Physician, Skilled Therapists, Nursing Staff

Mrs. A sees her primary care physician and voices a concern of feeling more unsteady on her feet, even experiencing a couple of falls in the past month. She also relates not having the same physical endurance as she has been accustomed to making it difficult to ambulate, get up out of a chair or off of the toilet, and becoming short of breath when walking even short distances.

Dr. J. refers Mrs. A to a local Physical Therapy Group for assessment and treatment of ambulation ability and muscle strengthening. Along with the referral for physical therapy Dr. J provides the therapy group with a report of Mrs. A’s last physical examination which was completed six months prior, including lab and x-ray results taken at that time.

Mrs. A also had a bone density exam two years prior and that was made available to the therapy group.

The Physical Therapy Group completes their assessment of Mrs. A and determines she could indeed benefit from muscle strengthening exercises, ambulation and transfer training. They schedule her for treatments three times per week. Along with providing follow up reporting to the primary care physician who referred Mrs. A, the therapy group also reports to the other care setting(s) that are involved with Mrs. A on a daily basis (i.e., in this example either the Nursing Home of the Home Health Agency) to ensure continuity and consistency of care.