How do I refer a patient to Physical Therapy (PT) for deconditioning and ataxic gait?

Documenting a Physical Therapy Referral for Deconditioning and Unsteady Gait

To properly document a physical therapy referral for a patient with deconditioning and unsteady gait, include a diagnosis of "generalized weakness and deconditioning with unsteady gait" in your referral, along with specific functional deficits and mobility concerns. 1, 2

Essential Components for PT Referral Documentation

Primary Documentation Elements:

• Diagnosis: "Generalized weakness/deconditioning with unsteady gait" 1
• Reason for referral: Specify "evaluation and treatment for deconditioning and gait instability" 2
• Functional limitations: Document specific activities affected (e.g., "difficulty with ambulation, transfers, balance") 1
• Risk assessment: Note any falls within past year or concerns about falling 2

Objective Findings to Include:

• Mobility assessment results: Document findings from standardized tests such as:
  • Timed Up and Go (TUG) test results (>12 seconds indicates fall risk) 2
  • 4-Stage Balance Test performance (inability to hold tandem stand for 10 seconds indicates increased fall risk) 2
• Gait characteristics: Document specific abnormalities (e.g., ataxic pattern, widened base of support, reduced step length) 3
• Strength deficits: Note any muscle weakness contributing to gait instability 4

Treatment Goals to Specify

Include specific functional goals in your referral:

• Improve balance and stability during ambulation
• Increase overall strength and endurance
• Enhance functional mobility for activities of daily living
• Reduce fall risk
• Develop home exercise program for continued conditioning 1, 2

Special Considerations

For Elderly Patients:

• Note any comorbidities that may affect therapy (cardiovascular disease, respiratory conditions) 1
• Document medication review if any could contribute to balance problems 2
• Specify if patient requires assistive devices currently 2

For Post-Illness Deconditioning:

• Note duration of bedrest or inactivity if applicable 4
• Document any specific illness that led to deconditioning 1
• Include any precautions related to recent hospitalization 5

Follow-up Documentation

Include expectations for follow-up in your referral:

• Request for PT assessment and treatment plan
• Recommendation for frequency and duration of therapy
• Request for progress reports at specific intervals
• Plan for reassessment of mobility using standardized measures 2

Common Pitfalls to Avoid

• Providing vague descriptions like "general deconditioning" without specific functional limitations
• Failing to document objective measures of mobility and balance
• Omitting fall risk assessment information
• Not specifying treatment goals or expected outcomes
• Neglecting to include relevant medical history that may affect therapy approach 1, 2, 3

By including these specific elements in your PT referral documentation, you ensure the physical therapist has comprehensive information to develop an appropriate treatment plan for the patient's deconditioning and unsteady gait, ultimately improving their mobility, safety, and quality of life.