After a mobility assessment, what should be documented?

Documenting the patient's mobility status, test scores, observed behaviors, and interventions performed provides a comprehensive view of the patient's condition and the care provided. This thorough documentation is crucial for several reasons.

Firstly, it enables healthcare providers to track changes in the patient's mobility over time, which is essential for assessing progress and making informed decisions regarding treatment. Detailed information about mobility status helps in understanding baseline capabilities and setting realistic goals for rehabilitation.

Including test scores adds an objective measure to the assessment, allowing the healthcare team to evaluate effectiveness and determine if the patient is responding appropriately to interventions. Observed behaviors are vital as they provide context to the numerical data, showcasing how the patient functions in real-life situations and contributing to a holistic understanding of their mobility challenges.

Lastly, documenting the interventions performed informs continuity of care, ensuring that all team members are aware of the approaches used and can build upon those efforts in future sessions. This comprehensive documentation is part of best practices in patient care, allowing for better communication among healthcare providers and supporting tailored treatment plans.