http://www.cyberpt.com/ptforum/ Copyright (c) 2006-2013 Web Wiz Forums - All Rights Reserved. Fri, 03 Apr 2026 13:55:37 +0000 Tue, 08 Jul 2008 00:35:17 +0000 http://blogs.law.harvard.edu/tech/rss Web Wiz Forums 11.03 360 www.cyberpt.com/ptforum/RSS_post_feed.asp?TID=7 http://www.cyberpt.com/ptforum/forum_images/pt_logo.gif http://www.cyberpt.com/ptforum/ http://www.cyberpt.com/ptforum/forum_posts.asp?TID=7&PID=7&title=daily-note#7 Author: Ask a PT
Subject: 7
Posted: Jul 08 2008 at 12:35am

Our user asked: "I am a PT working on an acute rehab unit. We currently do narrative daily notes, and I am trying to create an easier/quicker form to document on which would capture all essential information. Any ideas?"

Ask a PT Response: "I know alot of organizations are moving towards an electronic medical record system. I have seen Centricity being used at two large hospitals. http://www.centricityusers.com/ . This program seems to work fine for documentation of inpatient records but is not as efficient for outpatient services.

As far as coming up with a form, perhaps you could use check boxes and incorporate sections for the various parts of a progress note to be filled in. A simplified form which you just fill out sections and check boxes may be a lot quicker than narrative notes. You can make it as detailed or as general as you would want it. Below is something quick I came up with.


S: pain (0-10/10) pre__ post__ etc.......
O: Transfers: sit to stand __ min A __mod A __ max A __CGA __SBA __Ind
stand to sit __ min A __mod A __ max A __CGA __SBA __Ind
Bed Mobility: sup to sit __ min A __mod A __ max A __CGA __SBA __Ind
sit to sup __ min A __mod A __ max A __CGA __SBA __Ind
Gait:
Assitive Device __Walker __W/W __cane __crutches __HHA __None
Weight Bearing __NWB __TTWB __PWB __FWB
ROM:
Strengh:
Balance:
Other:
A:
P: Con't with POC ___ Comments:
Discharge from PT ___ Comments:

I hope this helps. Thanks for using CyberPT."]]> Tue, 08 Jul 2008 00:35:17 +0000 http://www.cyberpt.com/ptforum/forum_posts.asp?TID=7&PID=7&title=daily-note#7