PHYSICAL THERAPY
□ INITIAL EVALUATION □ RE-ASSESSMENT □ 13th VISIT □ 19th VISIT □ 30 DAY □ RECERTIFICATION
PATIENT’S NAME:
DOB
TREATMENT Dx:
ONSET
/
/
/
SOC:
/
/
MR#
/
a.m.
p.m.
TIME IN
TIME OUT
a.m.
p.m.
MEDICAL Dx & PERTINENT Hx:
PRIOR LEVEL OF FUNCTION & LIVING SITUATION:
PRECAUTIONS:
MENTAL STATUS: □Alert □Oriented x ___
REHAB POTENTIAL:
PAIN: □NO □YES (0-10 Scale) Description / Location(s):
Comments:
VITALS: BP: □At Rest
□w/ Activity
HOMEBOUND: □NO □YES Reason(s):
□ Taxing effort to leave home
□ Needs assist for all activities □ Severe SOB/SOBE
□ Unsafe to leave home alone □ Medical restrictions
□ W/C or Bed bound
□ Residual weakness
□ Confusion
□ Other:__________
Increases By:
Relieved By:
HR: □At Rest
□w / Activity
RESP:
O2 Sat:
NT
ROM DEFICITS
Mo
d
Ma
x
Dep
SB
A
CG
A
Min
Ind
PRESENT LEVEL OF
FUNCTIONAL MOBILITY:
MI
STRENGTH DEFICITS
G
GF+
F
BALANCE
Sitting Static
Sitting Dyn
Stand Static
Stand Dyn
SAFETY
ENDURANCE
SENSATION:
COORINATION:
MUSCLE TONE:
SKIN INTEGRITY:
Home Assessment/Safety Measures:
F-
P+
P
UA
Standardized/Functional Test(s):
□BERG □Tinetti □TUG
□Other: _______
Score: ________ (attach form)
Rolling R/L
Bridge / Scoot
SupineSit
DME in Home/Recommendations:
SitStand
BedChair
Toilet
Shower / Tub
Car Transfer
WC Mobility
Gait
Stairs
Gait Analysis: □Level □Uneven Distance: ________ ft. AD Used: __________ Gait Deviations____________________________________________
Stairs: # Steps:
Rails: □0 □1 □2 AD Used:
W/C Mobility:
TREATMENT PROVIDED THIS VISIT:
PROBLEM LIST/ SKILLED PT NEEDED TO ADDRESS:
POC discussed and agreed upon by pt / cg? □ Yes □ No
□ Evaluation
□ Re-Evaluation
□ Bed Mobility
□ Therapeutic Exercise
□Strength □Endurance □ ROM
□ W/C Mgmt / Propulsion Training
GOALS-Short Term:
D/C planning with pt/cg? □ Yes□ No
PHYSICAL THERAPY TREATMENT ORDERED/ PLAN OF CARE:
□ Transfer Training
□ Gait Training
□ Balance/Coordination
Time Frame/#visits:
□ Neuromuscular Re-Educat. □ Establish/Upgrade HEP
□ Prosthetic / Orthotic
□ Pt/Cg Education
□ Perceptual Motor Training □ Other:_______________
GOALS-Long Term:
Time Frame/#visits:
OBJECTIVE & MEASURABLE PROGRESS TOWARD S GOALS:
Frequency/Duration:
Physician Name:
□ Certification □ Recertification From:_______________ To: _________________
Physician Signature/Date:
Patient’s Signature:
PT Signature/Date of Verbal Order for PT Plan of Care:
Reprinted with Permission from Health Staff for Hire, © Houston, TX 2011