Case Study
Admitting Diagnosis: Pneumonia
Specialty Program: Pulmonary
Discharge Location: Home
A 55-year-old gentleman was admitted to Cedar View Rehabilitation and Healthcare Center from Holy Family Hospital on October 30, 2020 for skilled nursing and therapy services to safely return home. Upon admission, Mr. H. was evaluated by and participated in skilled occupational and physical therapy where he was noted to require contact guard assistance for most self-care tasks, to transfer and ambulate 50 feet, standby assistance to perform bed mobility and was noted to have decreased balance and activity tolerance increasing his risk for falls. As he progressed with his therapy goals, he was able to participate in higher level functional activities such as stair training and car transfers while maintaining his safety. Upon discharge, Mr. H. was able to perform all self-care tasks, bed mobility, transfer, ambulate 1000 feet with no adaptive device and ascend and descend 12 stairs independently while maintaining his low fall risk tasks. He made great gains toward his therapy and was able to return home with home care services. Great work Mr. H.!
10.0 – Complete Independent – No assist, no equipment
9.0 – Modified Independent – No Assist, but equipment or extra time
8.0 – S/u – No physical assist other than set-up; supervision for safety/technique; and/or single cue to initiate
7.0 – Supervision-No physical assist; supervision for safety/technique; and/or single cue to initiate
6.0 – SBA-Pt. performs task with close supervision and or visual/verbal cues for task completion
5.0 – CGA – Contact Guard Assist
4.0 – Min – Occasional assist (25% or less time or effort to complete)
3.0 – Mod – Frequent assist (40-50% of the time or effort involved to complete task
2.0 – Max – Constant assist (75-90% of the time or effort involved to complete task
1.0 – CD – Complete Dependence: No contribution from pt; task done by others or not assessed
Case Study
Admitting Diagnosis: Spinal Fusion, Lumbar Region
Discharge Location: Home
A 67-year-old female was admitted to Cedar View Rehabilitation and Healthcare Center from Lawrence General Hospital for skilled nursing and therapy services to safely return home. Upon admission, Mrs. T. was evaluated by and participated in skilled occupational and physical therapy where she was note to require moderate/maximum assistance for most selfcare tasks, bed mobility, transfers and gait and was noted to have decreased balance and activity tolerance increasing her risk for falls. As she progressed with her therapy goals, she was able to participate in higher level functional activities such as balance training, stair training and car transfers while maintaining her safety. Upon discharge, Mrs. T. was able to perform all selfcare tasks, bed mobility, was able to transfer and ambulate 100 feet with modified independence and was able to ascend and descend 4 stairs with supervision. She was a low fall risk and had decreased pain. She made great gains toward her therapy goals and was able to return home with strong family support and home health services. Great work Mrs. T.!
10.0 – Complete Independent – No assist, no equipment
9.0 – Modified Independent – No Assist, but equipment or extra time
8.0 – S/u – No physical assist other than set-up; supervision for safety/technique; and/or single cue to initiate
7.0 – Supervision-No physical assist; supervision for safety/technique; and/or single cue to initiate
6.0 – SBA-Pt. performs task with close supervision and or visual/verbal cues for task completion
5.0 – CGA – Contact Guard Assist
4.0 – Min – Occasional assist (25% or less time or effort to complete)
3.0 – Mod – Frequent assist (40-50% of the time or effort involved to complete task
2.0 – Max – Constant assist (75-90% of the time or effort involved to complete task
1.0 – CD – Complete Dependence: No contribution from pt; task done by others or not assessed
