Documenting Increased Weakness
- Was able to pivot
- Slept 12 of 24 hours
- Ambulated independently with walker
- Able to sit upright in chair
- Able to self-propel wheelchair
- Able to engage in 30 minutes of singing favorite songs
- Was interested in [XYZ] activities
- Unable to bear weight
- Sleeps 18 to 24 hours
- Ambulates with walker, but now requires assistance
- Requires lateral arm support, support with pillows, geri chair, foot rests, etc.
- Unable to self-propel in wheelchair
- Only able to listen to songs; unable to sing along
- No longer able to participate in activities
Documenting Mental Status
Is/Does the Patient:
- Able to make needs known?
- Recognize family members?
- Respond to name only?
- Wander aimlessly?
- Stare blankly or stare off into space?
- Respond to tactile/auditory stimuli?
- Maintain eye contact or visually track?
- Able to smile? Flat affect? Hold head upright?
- Laugh inappropriately?
- feed required?
- Unable to utilize silverware?
- Requires prompting/encouragement to accept food, chew, swallow?
- Exhibits prolonged chewing time/difficulty swallowing?
- Pockets food?
- Expresses no interest in food?
- Plays with/throws food?
- Takes food from others’ plates?
- Finger food only?
- How much does patient eat? Percentages are subjective, so be specific (e.g., patient consumed 2 bites of sandwich and 4 teaspoons of Jell-O). 100 percent of a piece of toast and 6 oz of tea cannot be compared to 100 percent of a steak dinner with potatoes, salad and dessert!
- Does the patient cough after eating or drinking?
- Is it taking longer to feed the patient?
- Is the patient refusing food?
Is Patient’s Speech:
- Responds to yes/no questions only?
- Inappropriate responses?
- Is speech repetitive?
Documenting Weight Loss:
- Is the patient’s weight being recorded. Is there a decline?
- Is weight loss evidenced by loose-fitting clothes, belt that is now too big, and/or extra skin folds?
- Are bony prominences evident or is patient skeletal in appearance?
- Does the patient look thinner when compared to a photo taken in healthier days?
- Requires standby, one or two person assist?
- Requires Hoyer lift?
- Does patient lean to the side in wheelchair? (This relates to FAST score 7d and indicates patient cannot maintain posture.)
- Has patient lost the strength to lift feet off the ground when transported in a wheelchair?
- Does patient need a geri chair or Broda chair?