Published May 27, 2014
KimWill19
3 Posts
Hello, I have a concept map due in 2 days for a PT in Rehabilitation for a fall. In the chart, it doesn't list any current medical diagnosis. ( Diagnosis 1, Diagnosis 2, etc). It seems to be blank in that section. All it pretty much says about the pt is "91 y.o female fell in assisted living home. says she does not remember how she fell. Pt also was treated for UTI, had a DVT in right leg, and is now at (this facility) for rehabilitation OT/PT."
She is on 2 meds. One that she takes every morning, and the other she takes once a week.
She is continent, and seems to remember her ADL's, her family, crossword puzzles, she can read the time, remembers when she last went to the bathroom, knows her bday . etc.. basically shes A+Ox2 to name and time.
I've only worked with her for one day, and basically throughout the day I administered a bed bath, dressed her, helped her to her wheelchair, toileted her, elevated her feet in wheelchair, with assistance to the best of her ability..and she worked with OT/PT through the day and also got her hair done at the salon.
Need help figuring out what to do for "Reason Seeking Healthcare" and the diagnosis. Not sure if it would be more relevant to do it on the DVT, or UTI ?
BTW, I assumed the DVT is taken care of considering she's not in a heparin drip.