Physio Initial Inpatient

Reason for referral: [State reason for referral to physiotherapy, e.g. functional decline post viral illness] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) HOPC: - [Briefly summarise patient's reason for admission to hospital] - [Summarise patient's need for physiotherapy whilst in hospital] - [Summarise any clinical complaints the patient has that are related to physiotherapy, e.g. worsening leg pain, large headache etc] - Medications: See med chart PMHx: - [Document any relevant past medical history related to the patient's condition, such as hypertension, diabetes, prior stroke, TB, or HIV status (if relevant)] (Only include if explicitly mentioned.) SH: - [Summarise patient's living situation, including type of accommodation (e.g. RDP home, flat, shack), who they live with, availability of running water/electricity if relevant] - [Describe the patient's previous level of function prior to admission, specifically mobility status, personal and domestic ADLs (e.g. use of walking aid, independence with bathing/cooking)] - [Describe the patient's exercise tolerance prior to admission (e.g. able to walk to local shop, attend church, community group)] - [Summarise patient's current home support services, e.g. CHW visits, family support, SASSA grant dependency, community feeding scheme participation] - [History of falls in past 12 months] (Only include the above if explicitly mentioned.) Objective: - [Describe how you found the patient on entrance, e.g. Resting in bed (RIB), Alert + Oriented (A+O), saturating comfortably on 2L O₂ via nasal prongs] - Vitals observations: [State whether they are Between the Flags (BTF) or not, based on hospital early warning scoring system] - [Describe any attachments the patient may have, e.g. indwelling catheter (IDC), IV line, oxygen tubing, drains, etc] - Auscultation: [Describe auscultation findings, e.g. decreased breath sounds LLZ with inspiratory crackles] - Lateral Basal Expansion (LBE): [Thoracic lateral basal expansion findings] - Cough: [Clinically describe cough, e.g. strong, dry, productive, effective/ineffective] - CXR: [Describe chest X-ray findings if available from state or private imaging centres] - [List any other appropriate and/or relevant information, e.g. pain score, oxygen requirements, positioning limitations, pressure sore risk] (Only include the above if explicitly mentioned.) Mobility: - Supine → SOEOB: [describe patient's ability to move from supine to sitting on edge of bed] - Sit Bal: [describe patient's sitting balance] - STS: [describe patient's sit-to-stand ability] - Stand Bal: [describe patient's ability to maintain standing balance] - Transfer: [describe patient's ability to transfer, including aids used and level of assistance] - Walking: [describe patient's walking ability, including aid used, assistance level, and limitations, e.g. shortness of breath, pain, fatigue] (Only include if explicitly mentioned.) Treatment: - [List treatment provided to patient, e.g. education on risks of prolonged bedrest, ACBT (Active Cycle of Breathing Techniques) x2 rounds, mobilised 2x8m on corridor with walking frame, etc] (Only include if explicitly mentioned.) Assessment: - [Summarise how nurses should transfer/mobilise the patient on the ward, e.g. 2x assist with walking frame, or mobilise independently with supervision] - [State whether the patient is or is not at baseline function] (Only include if explicitly mentioned.) - [State whether the patient is safe or not for discharge from physiotherapy, with justification, e.g. able to safely mobilise independently and negotiate steps at home] - [State any barriers affecting discharge from physiotherapy, e.g. has 12 stairs at home, no handrail, lives alone, no access to walking aid] (Only include if explicitly mentioned.) Plan: - [State any recommendations for the doctors or other members of the multi-disciplinary team to action and/or be aware of, e.g. request OT for ADL assessment, review analgesia for mobility] - [State next physiotherapy review date, e.g. re-assess in 2 days, r/v 2/7] - [State goal of next physiotherapy session, e.g. mobilise to toilet with supervision, progress to stair assessment, improve standing balance] (Only include if explicitly mentioned.) (Please note, patients in South African public and private acute hospitals are often referred to physiotherapy for functional decline secondary to a primary illness/condition such as pneumonia, fracture, or stroke.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or continuing care – use only the transcript, contextual notes, or clinical note as a reference. If any information related to a placeholder has not been explicitly mentioned, do not state that it has not been mentioned – simply leave the placeholder or section blank. Use as many bullet points as needed to capture all relevant information.)