Improving Vague Documentation Statements

"Patient is getting stronger."

• Patient feels their strength has improved since starting therapy.

• Patient demonstrates increased grip strength from 10 lbs to 18 lbs on the dynamometer.

• Patient appears to use less effort when lifting objects.

• Patient no longer complains of weakness during therapy sessions.

Answer explanation

This statement provides objective, measurable data to show improvement in strength rather than relying on subjective impressions.

"Patient has difficulty standing."

• Patient requires moderate assistance for standing, with increased postural sway.

• Patient is unable to stand for more than 5 minutes.

• Patient tolerates standing for 2 minutes before reporting fatigue.

• Patient frequently loses balance while attempting to stand.

Answer explanation

This statement specifies the level of assistance needed and includes an observable characteristic (postural sway), making it more clinically useful.

"Patient's coordination is bad."

• Patient has difficulty with fine motor tasks.

• Patient demonstrates dysmetria, overshooting objects by 2 cm when reaching.

• Patient shows inconsistent movement patterns when grasping small objects.

• Patient moves with some inaccuracy but completes tasks independently.

Answer explanation

This describes a specific motor coordination issue (dysmetria) with a quantifiable measure (overshooting by 2 cm), providing a precise clinical picture.

"Patient walks with difficulty."

• Patient ambulates with an uneven gait and frequent pauses.

• Patient ambulates 15 feet with a walker and minimal assistance, demonstrating mild left hip hiking.

• Patient sometimes appears unsteady when walking.

• Patient takes short steps and needs occasional support.

Answer explanation

This statement quantifies the distance walked, the level of assistance needed, and describes a compensatory movement (hip hiking), making it more informative.

"Patient’s endurance is low."

• Patient requires rest after completing 5 minutes of continuous activity due to fatigue.

• Patient demonstrates slowed movement when completing multiple tasks in succession.

• Patient is unable to sustain activity for more than a short period.

• Patient frequently stops during tasks due to shortness of breath.

Answer explanation

Endurance is best documented with specific activity duration before fatigue occurs, making this the most precise statement.

"Patient’s balance is poor."

• Patient frequently stumbles but does not require assistance to recover balance.

• Patient loses balance when reaching beyond arm’s length but recovers independently.

• Patient requires supervision for standing balance activities due to occasional instability.

• Patient exhibits mild postural sway but remains upright without external support.

Answer explanation

This describes the specific condition under which balance issues occur and provides functional implications while highlighting independence in recovery.

"Patient has weak grip."

• Patient struggles to hold objects securely for extended periods.

• Patient demonstrates 8 lbs grip strength in the right hand and 12 lbs in the left, below functional norms.

• Patient reports difficulty gripping heavy objects but manages light tasks.

• Patient’s hand strength varies depending on task complexity.

Answer explanation

Providing grip strength measurements allows for objective assessment and comparison to functional norms.

"Patient is unable to do self-care tasks."

• Patient requires assistance with lower-body dressing but completes upper-body dressing independently.

• Patient cannot perform daily self-care tasks independently.

• Patient struggles with fasteners and requires additional time for dressing.

• Patient needs reminders to initiate grooming tasks.

Answer explanation

This statement avoids generalization and instead specifies which self-care tasks the patient can and cannot perform.

"Patient has pain when moving."

• Patient reports occasional discomfort in the right shoulder with overhead reaching.

• Patient rates shoulder pain at 6/10 during overhead reaching.

• Patient avoids certain movements to prevent pain but does not require medication.

• Patient demonstrates hesitation before initiating movement.

Answer explanation

Pain documentation should include intensity (numeric rating scale) and the specific movement that triggers discomfort.

"Patient gets tired easily."

• Patient slows down while completing multi-step tasks but does not require rest breaks.

• Patient requires seated rest after 5 minutes of continuous activity due to fatigue.

• Patient completes morning self-care activities but requires assistance in the afternoon.

• Patient demonstrates reduced endurance but remains engaged in activities.

Answer explanation

This statement quantifies endurance limits and specifies when fatigue occurs, making it clinically useful.