DOS: mm/dd/yyyy

Time in: 0000

Time out: 0000

Subjective:
*X-year-old FEMALE/MALE, presenting with chief complaint of TYPE/LOCATION/DESCRIPTION.
*MOI. PMH. HOI. Imaging/Dx.
*Compared to PLOF, pt reports difficulty participating in X.
*Pt reported goal(s) for physical therapy include X.
*Pt describes their overall health as X.
*Additional factors affecting pt outcome status include X(social support, cognitive,
comorbidities, services).
*Current medication, allergies, and comorbidities as per electronic health record. Pt reports
comorbidities and other health issues are appropriately managed.
*Pt reports no history of falls within the past 6 months.
*Pt reports no fevers, chills, or night sweats. No unexplained weight loss. No night pain.
*Pt reports no ENT, vision, pulmonary, cardiac, gastrointestinal, or bowel/bladder issues.
*Pt reports no numbness, tingling, and/or symptoms of radiculopathy.

“0" represents “unable to perform” and "10" represents “able to perform at prior level”.
PSFS – Activities Initial d/m/
y
1.
2.
3.
4.
5.

Objective:
* No readily visible atrophy, erythema, bruising, etc.
*Girth and mechanical alignment are grossly symmetrical and normal.
*Gait is grossly symmetrical and normal.
*Posture: Pt in sitting/standing presents with X(FHP, protracted shoulders, kyphosis, lordosis,
scoliosis, ant/post pelvic tilt, etc).
*Balance: Pt reports no balance issues or fear of falling. () SLS.
*Neurological Assessment:
 UE: () cervical quadrant, () spurling/distraction, () C5/C6/C7 reflex/dermatome,
() thumb ext, () digit abd/add, () OK sign.
 LE: () toe march, () heel march, () great toe ext, () lumbar quadrant, () slump, () piriformis,
() L4/S1 reflex/dermatome, () protective plantar sensation.
 Notes…
*Musculoskeletal Assessment:
 AROM:
o R/L/B JOINT – X of X, X of X. Restricted by X(pain, stiffness, body habitus).
  PROM:
o R/L/B JOINT – X of X, X of X. Restricted by X(pain, stiffness, body habitus).
 Arthrokinematics:
o R/L/B JOINT – hyper/hypomobile in MVMT glide.
 MMT:
o R/L/B JOINT – X/5 MVMT. Restricted by X(pain, stiffness, body habitus).
 Palpation: TTP along X. Tone, swelling, etc.
 Special Tests:
o Neck: () TOS (Adson/Eden/Wright), () VBI, () AROM/PROM, () AM.
o Shoulder: () scarf, () ACJ shear, () full can, () empty can, () Gerber’s, () ERLS, () Hornblower’s,
() O’Brien’s, () Apprehension/Jobe, () bicep’s load, () AM.
o Elbow: () valgus, () varus, () Tinel’s, () supinator, () pronator, () AM.
o Wrist/Hand: () Finklestein’s, () thumb valgus, () anatomical snuff box, () AM.
o Lumbar/Hip: () flex/ext centralization, () scour, () FADIR, () FABER, () AM.
o Knee: () 5°/20° Thessaly, () stroke test, () 5°/30° valgus, () 30° varus, () Lachman,
() ant drawer, () post drawer, () tibial joint line, () AM.
o Ankle/Foot: () Kleiger’s, () ant drawer, () inversion stress, () eversion stress, () shuck, () Tinel’s
tarsal, () windlass, () AM.
 Notes…
*Functional Assessment:
 Notes on how patient performed functional tasks, including PSFS.

Treatment:
*97110: Therapeutic exercise program performed today one on one for XXX minutes in
duration focusing on *developing strength, endurance, range of motion, and flexibility*.
Exercises were performed pain free during today’s clinical visit, including:
 Straight leg raises - 2 sets of 15 reps w/ 10-pound cuff weights; emphasis on setting
quad before lifting weight.
 ITB stretch - 3 reps each w/ 30-second holds; verbal cues needed to hold position to
sustain stretch.
 Passive scapulothoracic mobility, all planes - 10 reps each x 2 sets; educated patient
about GH joint biomechanics
*97112: Neuromuscular re-education program performed today one on one for XXX minutes in
duration focusing on *movement, balance, coordination, kinesthetic sense, posture, and/or
proprioception*. Exercises were performed pain free during today’s clinical visit, including:
 Open-chain right shoulder exercises; 3×10 with eyes closed. Manual cues provided to
facilitate proper scapulohumeral rhythm and position sense.  
 Controlled descent from 6” step standing on R LE x 10 reps; verbal cues for alignment of
hip, knee, and ankle
 Mini-tramp controlled landings to half-squat x 10 reps; verbal cues for alignment of hip,
knee, and ankle
 Single-leg mid-stance on involved leg in parallel bars w/ hand touch for safety; 5 trials
for 1 minute each; manual cues to sustain hip abductor contraction
*97530: Therapeutic activities education program performed today one on one for XXX minutes
in duration focusing on *dynamic activities to improve functional performance*. Exercises were
performed pain free during today’s clinical visit, including:
 Floor to waist to shoulder-level lifting of 15-pound 2′ x 2′ box to simulate picking up
patient’s 1-year-old grandchild
 Modified American kettlebell swings x 5 reps with manual cues to control the squat with
glute contraction, hips positioned over ankles; visual cues to verify alignment of ankles
and hips using mirror
 Adaptive lift simulation with pillow filled with 10-pound and 30-pound cuff weights x 3
reps each; verbal cues needed for patient to squat down and keep weight close to her
trunk w/ load primarily supported by right UE; diagrams w/ written instructions
provided for home use
 Posture review w/ L UE reach to shoulder level, 10 reps each w/ 1- and 2- pound
weights; needs mirror for visual cues plus occasional manual correction to maintain
neutral trunk position

Assessment:
*Pt is a X-year-old FEMALE/MALE presenting with signs and symptoms consistent with XICDX.
HOI and MD-Dx. Pathological findings include X(neurological and musculoskeletal assessment).
Activity limitations reported by pt include X(PSFS/functional assessment). Pt performed X(PSFS).
PT medically necessary to restore functional deficits and progress pt return to required ADLs. PT
also medically necessary to educate pt on proper HEP and pathology management to
ameliorate risk factors and avoid reoccurring episodes. Additional factors affecting pt outcome
status include X(social support, cognitive, comorbidities, services). Prognosis is good with
regular adherence to rehab plan prescribed today.

*Personal factors: 2 – impact of pain and dysfunction on ability to perform occupational and
recreational tasks, comorbidities including exercise tolerance and current activity level.
*Body system elements examined: 3 – 1) overall structure of the area evaluated today, 2)
assessment of symmetry, range of motion and strength and 3) assessment of participation
restrictions for occupational and/or recreational tasks.
*Level of complexity: moderate with evolving presentation.

Plan of Care:
1. Implement a skilled rehabilitative program focused on improving functional strength
and range of motion with a gradual return to patient’s desired level of activity and
participation. This will be achieved via patient education, therapeutic exercises,
therapeutic activities, neuromuscular re-education, and appropriate use of manual
therapy techniques. Patient is advised on the importance of maintaining their rehab
plan and following HEP provided at initial consultation. Reassess functional limitations at
60 days or 13th treatment session, or as needed, to determine effectiveness of
treatment.
2. Monitor rehab program to address any evolving deficits and progress patient’s
functional load. Pt instructed to…
 a. integrate daily aerobic exercise to begin progressing towards the HHS
recommendation of adequate health (150 min of mod-int aerobic).
b. integrate functional strengthening at least three times per week for a minimum
of 20 minutes per session.
3. *Follow up treatment sessions X times a week, for X-X weeks, to progress as needed.
*Pt educated on the role of physical therapy in their health assessment, advised to
follow HEP prescribed during exam and contact clinic if they wish to continue treatment.

Pt verbally demonstrated an understanding of the above written POC and assessment, and
consents to treatment.
*Pain addressed today with physical therapy intervention. All interventions tolerated well and
patient reports less pain after visit today.
Prognosis for full recovery and progression towards long term goals is good following the
prescribed treatment plan.

Goals:
*"SMART" goals are "specific," "measurable," "attainable," "relevant," and "time-bound."
*Short term (2-3 weeks):
 Pt will perform X exercise with X(pain >X/10, with #lb weight, time, ind, etc) to demo
improved X(deficit) by X-X weeks.
 Pt will perform X exercise with X(pain >X/10, with #lb weight, time, ind, etc) to demo
progression towards return to X(participation) by X-X weeks.
 Pt will report GROC of 3, decrease in pain at worst to X/10 lifting X pounds overhead by
X-X weeks.
*Long term (4-6 weeks):
 Pt will perform X exercise with X(pain >X/10, with #lb weight, time, ind, etc) to demo
improved X(deficit) by X-X weeks.
 Pt will perform X exercise with X(pain >X/10, with #lb weight, time, ind, etc) to demo
progression towards return to X(participation) by X-X weeks.
 Pt will report GROC of 6, decrease in pain at worst to X/10 lifting X pounds overhead by
X-X weeks.
 Pt will demo HEP without cues, safely progressing difficulty of exercises as needed to
increase physical capacity, in order to demonstrate independence with rehab program
by X-X weeks.

Greg Schwartz, SPT