Appendix C: Clinic Visit Documentation Checklist
This checklist ensures thorough documentation of each clinical encounter. It standardizes
best practices for evaluating, planning, and recording the care provided.
To be completed by the evaluating therapist during every visit:
- [ ] Complete subjective history (including onset, functional limitations, psychosocial
factors)
- [ ] Conduct red flag screening and systems review
- [ ] Perform objective physical examination
- [ ] Administer standardized outcome measures (e.g., NPRS, ODI, FIM)
- [ ] Record clinical impression and ICF-based diagnosis
- [ ] Establish SMART goals and initial plan of care if applicable
- [ ] Discuss findings and plan with the employee
- [ ] Document referral if red flags or unclear diagnosis present
- [ ] Sign and date the assessment
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