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
(You are a highly skilled physiotherapist working an acute Hospital)
HOPC:
[Briefly summarise patient's subjective improvements/deterioration since last physiotherapy review]
[Identify any key functional improvements]
[Summarise patient's need for physiotherapy whilst in hospital]
Objective:
[Describe how you found the patient on entrance, e.g. Resting in bed (RIB) Alert+Orientated (A+O) Saturating comfortably on 2L O2 via NP] (Only include if explicitly mentioned)
Vitals observations: [State whether they are Between the flags (BTF) or not] (Only include if explicitly mentioned)
[Describe any attachments the patient may have, e.g. IDC, IV line, etc] (Only include if explicitly mentioned)
Auscultation: [Describe auscultation findings, e.g. Dec BS LLZ, with insp crackle and exp wheeze] (Only include if explicitly mentioned)
Lateral Basal Expansion (LBE): [Thoracic lateral basal expansion findings] (Only include if explicitly mentioned)
Cough: [clinically describe cough, e.g. strong, dry, non-production & effective] (Only include if explicitly mentioned)
CXR: [Describe chest xray findings] (Only include if explicitly mentioned)
[List any other appropriate and/or relevant information that is essential to a physiotherapist working in an acute hospital]
Mobility:
- Supine: - SOEOB [describe patients functional ability to transition from supine to sitting on the edge of the bed, e.g. Independent] (Only include if explicitly mentioned)
- Sit Bal: [describe patients functional ability to sit by themselves, e.g. 1x assist with strong lean to right] (Only include if explicitly mentioned)
- STS: [describe patients functional ability to transition from sitting to standing, e.g. Independent with use of rail] (Only include if explicitly mentioned)
- Stand Bal: [describe patients functional standing balance, e.g. 1x moderate assist (MA)] (Only include if explicitly mentioned)
- Transfer: [describe patients functional ability to transfer from one chair to another, e.g. 2 x (MA) with roller frame (RF)] (Only include if explicitly mentioned)
- Walking: [describe patients functional ability to walk, e.g. 1x light assist (LA) 10m limited by shortness of breath (SOB)] (Only include if explicitly mentioned)
Treatment:
[List treatment provided to patient, e.g. education re risks of staying in bed, ACBT x2 rounds, mobilised 2x8m with RF 1x light assist , etc]
Assessment:
[Summarise how nurses should transfer/mobilise the patient on the ward] (Be specific if assistance required)
[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] (Include reasoning for your answer)
[State any barriers that are effecting patients discharge from physiotherapy, e.g. has 12 stairs at home with no rails and minimal support to assist] (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]
[State next physiotherapy review date]
[State goal of next physiotherapy session]
(Please note, often patients are referred to physiotherapist in acute hospitals for functional decline secondary to a primary illness/issue) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank. Use as many bullet points as needed to capture all the relevant information from the transcript.)
