GOLDEN HILL  -  Therapy/Nursing Communication Form

Resident Name:                                                                                                       Date:         /        /              
PT
AMBULATION
distance/device/assistance/deviations
 
TRANSFERS
SUPINE to SIT
Assistance Level:    None  /  Limited  /  Extensive  /  Total Dependence
SIT to STAND
Assistance Level:    None  /  Limited  /  Extensive  /  Total Dependence
BED Mobility
Assistance Level:    None  /  Limited  /  Extensive  /  Total Dependence
W/C Mobility
Assistance Level:    None  /  Limited  /  Extensive  /  Total Dependence
BALANCE
Good  /  Fair  /  Poor
Limitations: LE strength / ROM / WB Status:____________
OT
ADLs
Upper Body
Assistance Level:    None  /  Limited  /  Extensive  /  Total Dependence
 
Lower Body
Assistance Level:    None  /  Limited  /  Extensive  /  Total Dependence
 
Feeding:
Grooming:                                                               Positioning:
Toileting:                                                                 Safety:
ST
DIET
 
Liquids
 
Aspiration
 
Cognition
 
Safety Judgement
 
Additional Concerns
 
Special Concerns: