Physio SOAP In-Patient

HOPC: The patient has shown moderate improvement in mobility since the last physiotherapy review. Key functional improvements include increased ability to perform bed-to-chair transfers independently. The patient requires continued physiotherapy to enhance mobility and strength while in the hospital. Objective: The patient was found resting in bed (RIB), alert and oriented (A+O), and saturating comfortably on 2L O2 via nasal prongs (NP). Vitals observations are between the flags (BTF). The patient has an indwelling catheter (IDC) and an intravenous (IV) line. Auscultation revealed decreased breath sounds (BS) in the lower left zone (LLZ) with inspiratory crackles and expiratory wheeze. Lateral basal expansion (LBE) was reduced bilaterally. The patient has a strong, dry, non-productive, and effective cough. Chest X-ray (CXR) showed mild left lower lobe consolidation. Mobility: - Supine: Independent - Sit Bal: 1x assist with strong lean to the right - STS: Independent with use of rail - Stand Bal: 1x moderate assist (MA) - Transfer: 2x moderate assist (MA) with roller frame (RF) - Walking: 1x light assist (LA) 10m limited by shortness of breath (SOB) Treatment: - Education regarding the risks of prolonged bed rest - Active Cycle of Breathing Techniques (ACBT) x2 rounds - Mobilized 2x8m with roller frame (RF) and 1x light assist (LA) Assessment: - Nurses should transfer/mobilize the patient with 1x moderate assist (MA) and use of a roller frame (RF) - The patient is not at baseline function - The patient is not safe for discharge from physiotherapy due to ongoing mobility issues and shortness of breath - Barriers to discharge include 12 stairs at home with no rails and minimal support to assist Plan: - Recommend doctors monitor respiratory status and adjust oxygen therapy as needed - Next physiotherapy review in 2 days - Goal of the next physiotherapy session: Improve walking distance and reduce shortness of breath