Saint Mungo's Hospital - IRD Department

Speech Therapy Daily Note

Inpatient Rehabilitation (Setting 2)

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NAME: James Krum 

MRN: H07311980

AGE: 64 year old               DOB: 12/25/1960

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SUBJECTIVE:

 

Patient completed treatment session at bedside. Patient alert cooperative, and agreeable to treatment. Patient indicating back pain is present nearly all the time. Would like to lay down after therapy. No family present today.

 

OBJECTIVE:

 

Patient completed visual scanning task by way of reading an appointment note. Patient missing majority of written information on left side of page. Required visual color contrast to locate information on the left. Also given vertical paper placement so patient read top to bottom to place all written information on the right side. Patient was able to successfully read in vertical plane. He preferred this over color contrasts. He was then asked to recall details of message; he was 43% accurate. Pt very tangential and unfocused during session. He wanted to call his son but could not figure out how to turn his phone on. Therapist indicated it was not charged so we placed this on the charger. He was motivated to call his son back, I assume their call was disconnected. He could not be redirected to therapy session until this was completed. He was able to make the call and text his son. Before session was even completed, he called his son again despite being in the middle of tasks. Patient highly unaware of environment this date and not  easily redirected.

 

ASSESSMENT:

 

Reduced attention impacts learning, insight and carryover. Patient navigating his phone well but is not always aware of his surroundings and social aspects of communication. 

 

Electronic signature: Katie Grainger, SLP 10/20/2024