Physical Therapy Clinical Note
Pt Name/#:
Significant Subjective Observations:
Subunit:
Date:
HOMEBOUND STATUS ‐ Mark all that apply
6 ‐ Bed‐bound
7 ‐ Wheelchair bound
8 ‐ Needs assistance with equipment
9 ‐ Other (specify) ______________________________________
1 ‐ Limited ambulation ________ ft.
2 ‐ Unsteady gait/poor balance
3 ‐ SOB with minimal exertion
4 ‐ Mental confusion
5 ‐ Fear of, or refuses, to leave home
ASSESSMENT ‐ Report significant findings to subunit and document contact below
BP: __________ P: ______ R:______ (before rx)/BP: __________ P: ______ R:______ (after rx) Vital signs
Location: Intensity (0‐10) _______________________
Pain
Pain Intervention
Mental status
Unchanged Changed (specify)
YES NO NA (Report significant changes & document contact below)
Diabetes: Any s/s of hypo/hyperglycemia?
Diabetes: Does patient have foot ulcers?
CHF: Any edema, weight gain, SOB?
Skin Integrity: Any redness/breakdown/pressure areas?
Medications review: List any new medications
Falls: Any falls since last visit?
Assessment Notes:
CARE COORDINATION
Yes
Location
No
If Yes, Who
Re:
MX Maximum assist
KEY: IN Independent
SBA Stand by assistance
TD Total dependence
MI Minimal assistance
N/A Not applicable
MO Moderate assistance Mark specific activity/activities performed in the following interventions. If no interventions provided in a section, mark entire section as NA.
MOBILITY/FUNCTIONAL INTERVENTIONS
N/A (No Interventions provided)
BED MOBILITY
Roll (left to right) IN
SBA
MI
Roll (right to left) IN
SBA
MI
IN
SBA
MI
Sit to supine Supine to sit IN
SBA
MI
Assessment:
MO
MO
MO
MO
MX
MX
MX
MX
TD
TD
TD
TD
HBS116‐srw
Pt Name/#:
Subunit:
BALANCE
N/A (No Interventions provided)
Static sitting IN
SBA
MI
Static standing IN
SBA
MI
Dynamic sitting IN
SBA
MI
Dynamic standing IN
SBA
MI
Assessment:
TRANSFERS
N/A (No Interventions provided)
IN
SBA
MI
Sit to stand Stand to sit IN
SBA
MI
Bed to chair/wheelchair IN
SBA
MI
Chair/wheelchair to bed IN
SBA
MI
MI
Bed to commode IN
SBA
Shower/tub IN
SBA
MI
Toilet IN
SBA
MI
Floor (Up/Down) IN
SBA
MI
Into car IN
SBA
MI
IN
SBA
MI
Out of car Adaptive Equipment Required:
Assessment:
Date:
MO
MO
MO
MO
MX
MX
MX
MX
TD
TD
TD
TD
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MX
MX
MX
MX
MX
MX
MX
MX
MX
MX
TD
TD
TD
TD
TD
TD
TD
TD
TD
TD
GAIT TRAINING
N/A (No Interventions provided)
Weight Bearing Status __________________Gait Distance _________________________
Level Surface IN
SBA
MI
MO
MX
TD
Uneven Surface IN
SBA
MI
MO
MX
TD
Outdoor surfaces IN
SBA
MI
MO
MX
TD
Step/stairs
IN
SBA
MI
MO
MX
TD
Device:
Cane (SPC)
Quad cane
Gait Deficits None
Initiating gait
Stopping
Steppage
Shuffling
Assessment:
Wheeled walker
Walker
Crutches
Other (specify): Cadence
Posture
Balance
Scissoring
Turning
Hip stability
Festinating
Circumducting
FALL PREVENTION INTERVENTIONS
Fall Risk Assessment
No
Compliance with Fall Precautions
Assessment:
Yes
Yes
TUG _____Tinetti
No
N/A
Step length
Ataxic
Trendelenburg
Antalgic
Other: _____________________
HBS116‐srw
Pt Name/#:
Subunit:
Date:
THERAPEUTIC EXERCISE N/A (No Interventions provided)
Passive Active Assistive Active Resistive
Specific Exercise(s)/Assessment: Objective ROM/Strength Measurements:
WHEELCHAIR MOBILITY
Interventions/Assessment:
N/A (No Interventions provided)
HOME PROGRAM: Instructions provided to
Instructions provided/response
Patient
Caregiver
SKILLED INTERVENTIONS TO BE PROVIDED NEXT VISIT:
SUPERVISORY VISIT
N/A PTA Present Not Present If assistant not present, date contacted re POC
CARE COORDINATION
Yes
No
If Yes, Who
Re:
DISCHARGE VISIT
Yes No
(If yes, complete PT Discharge Below)
Status at time of referral
Care provided
Goal status at D/C
Disposition at D/C
Functional Scores at D/C
M1830
M1850
M1860
Signatures:
Patient/Caregiver
Therapist
HBS116‐srw