INITIAL

PHYSICAL THERAPY CARE PLAN UPDATED

Diagnosis/ Reason for PT: ONSET:

Frequency and Duration: If applicable, portion of Plan of Care assigned to a PTA was discussed, explained to the PTA: Yes No N/A
INTERVENTIONS Locator #21
Evaluation Balance training /activities Teach hip safety precautions
Establish/ upgrade home exercise program Pulmonary Physical Therapy Teach safe/effective use of adaptive/assist
Copy given to patient Ultrasound to _____ at _____ x _____ min device (specify)
Copy attached to chart Electrotherapy to _____ for _____ min Teach safe stair climbing skills
Patient/Family education Prosthetic training Teach fall safety
Therapeutic exercise TENS to _____ for _____ min Pulse oximetry PRN
Transfer training with/without assistance Functional mobility training Heat/Cold to _____ for _____ min
Gait training with/without assistance Teach bed mobility skills Therapeutic massage to _____ x _____ min
OTHER INTERVENTION/TREATMENT:
Note: Each modality specify frequency, duration, amount and specify location:
SHORT TERM GOALS LONG TERM GOALS Locator #22
GENERAL GENERAL
Gait will increase tinetti gait score to _____ / 12 within ______ weeks. Gait will increase tinetti gait score to _____ / 12 within ______ weeks.
Will improve gait requiring ____ to _____ from _____ to ______ within ____ weeks. Will improve gait requiring ____ to _____ from _____ to ______ within ____ weeks.
BED MOBILITY BED MOBILITY
Pt. will be able to turn side (facing up) to lateral (left/right) within ____ weeks. Pt. will be able to turn side (facing up) to lateral (left/right) within ____ weeks.
Pt. will be able to butt scoot within _____ weeks. Pt. will be able to lie back down within _____ weeks.
Pt. will be able to sit up with/without assistance _______ within ______ weeks. Pt. will be able to sit up independently _______ within ______ weeks.

m
Pt. will be able to self reposition within ______ weeks.
BALANCE BALANCE
Will increase tinetti balance score to _____/16 within _____ weeks. Will increase tinetti balance score to _____/16 within _____ weeks.

E .co
Pt. will be able to reach steady static/dynamic sitting/standing balance Pt. will be able to reach steady static/dynamic sitting/standing balance
with/without assistance ______ within ______ weeks with/without assistance ______ within ______ weeks
TRANSFER TRANSFER
Pt. will be able to transfer from _________ to _________ with/without assistance Pt. will be able to transfer from _________ to _________ with/without assistance
_____ within ____ weeks.
STAIR/UNEVEN SURFACE
PL m
Pt. will be able to climb stair/uneven surface with/without assistance _____ steps #
_____ within ____ weeks.
STAIR/UNEVEN SURFACE
M ste
Pt. will be able to climb stair/uneven surface with/without assistance _____ steps #
_______ within ________ weeks.
_______ within ________ weeks.
MUSCLE STRENGTH MUSCLE STRENGTH
Pt. will be able to hold weigh _______ lb within ________ weeks. Pt. will be able to hold weigh _______ lb within ________ weeks.
Pt. will be able to oppose flexion or extension force over _____ within ______ weeks.
SA sy

Pt. will be able to oppose flexion or extension force over _____ within ______ weeks.
PAIN PAIN
Pain will decrease from ____/10 to ____ /10 within _______ weeks. Pain will decrease from ____/10 to ____ /10 within _______ weeks.
n

ROM ROM
Pt. will increase ROM of ________ by ______ degrees Pt. will increase ROM of ________ by ______ degrees
.p

flexion/extension within _____ weeks. flexion/extension within _____ weeks.

SAFETY SAFETY
w

Pt. will be able to use _____ with/without assistance to _____ feet within ______ weeks. Pt. will be able to use _____ independently to _____ feet within ______ weeks.
Pt. will be able to propel wheel chair _____ feet within _______ weeks. Pt. will be able to self propel wheel chair _____ feet within _______ weeks.
w

HEP will be established and initiated. Pt will be able to finalize and demonstrated to follow up HEP.
ADDITIONAL SPECIFIC THERAPY GOALS Locator #22
w

Note: Each modality specify location, frequency, duration, and amount.

Patient Expectation SHORT TERM Time Frame LONG TERM Time Frame

DISCHARGE PLANS DISCUSSED WITH: Patient/Family APPROXIMATE NEXT VISIT DATE:

Care Manager Physician Other (specify) PLAN FOR NEXT VISIT
CARE COORDINATION: Physician OT SN ST
MSW Aide PTA Other (specify)
REHAB POTENTIAL: Poor Fair Good Excellent
Equipment needed:
Patient/Caregiver aware and agreeable to POC: Yes No (explain):
Plan developed by: Date
Therapist Name/Signature/title

Physician signature: Date

Please sign and return promptly, if applicable
Original - Patient Chart Copy - Patient's Home Chart
PATIENT NAME - Last, First, Middle Initial ID#
Cruz & Sanz Health Services, Inc. PHYSICAL THERAPY
EVALUATION RE-EVALUATION

DATE OF SERVICE / /
OBJECTIVE DATA TESTS AND SCALES PRINTED ON OTHER PAGE. TIME IN OUT
HOMEBOUND REASON: Needs assistance for all activities Residual weakness TYPE OF EVALUATION
Requires assistance to ambulate Confusion, unable to go out of home alone Initial Interim Final
Unable to safely leave home unassisted
Dependent upon adaptive device(s)
Severe SOB, SOB upon exertion
Medical restrictions
SOC DATE / /
(if Initial Evaluation, complete Physical Therapy
Other (specify) Care Plan)

PT ORDERS: Evaluation Therapeutic Exercise Transfer Training Home Program Instruction Gait Training Chest PT
Ultrasound Electrotherapy Prosthetic Training Muscle Re-education Other:
PERTINENT BACKGROUND INFORMATION
TREATMENT DIAGNOSIS/ PROBLEM
ONSET / /
MEDICAL PRECAUTIONS:

MEDICAL HISTORY I PRIOR/CURRENT LEVEL OF FUNCTION

m
Hypertension Fractures Assistive Device: Prior level of function (ADL/IADL) Specify: (ADL/IADL On Problematic Areas)
Cardiac Cancer Needs:

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Diabetes Infection
Respiratory Immunosuppressed
Osteoporosis Open wound PL m Has:
Other (specify)
Current level of function (ADL/IADL) Specify: (ADL/IADL On Problematic Areas)
M ste
LIVING SITUATION
Capable Able Willing caregiver available
SA sy

Limited caregiver support (ability/willingness)

No caregiver available
n

HOME SAFETY BARRIERS:

PERTINENT MEDICAL/SOCIAL HISTORY AND/OR
.p

Clutter Throw rugs PREVIOUS THERAPY RECEIVED AND OUTCOMES

Needs grab bars Needs railings
w

Steps (number/condition)
Other (specify)
w

BEHAVIOR/MENTAL STATUS
w

Alert Oriented Cooperative

Conf used Memory deficits Impaired Judgement
Other (specify)

PAIN
INTENSITY: 0 1 2 3 4 5 6 7 8 9 10
LOCATION:
AGGRAVATING /RELIEVING FACTORS:

PAIN TYPE (dull, aching, etc):

PATTERN (Irradiation):

VITAL SIGNS/CURRENT STATUS

BP: T.P.R.: Edema: Sensation:
Skin Condition: Muscle Tone: Posture:
Communication- Vision: Hearing:
Endurance: Orthotic/ Prosthetic Devices:
PART 1 - Clinical Record PART 2 - Therapist
PATIENT/CLIENT NAME - Last First, Middle Initial ID#

PHYSICAL THERAPY EVALUATION

 Cruz & Sanz Health Services, Inc. PHYSICAL THERAPY (Cont'd.)
EVALUATION RE-EVALUATION

MUSCLE STRENGTH/FUNCTIONAL ROM EVAL FUNCTIONAL INDEPENDENCE/BALANCE EVAL

STRENGTH ROM ASSIST
AREA ACTION

BED MOBILITY
Right TASK ASSISTIVE DEVICES/COMMENTS
Left Right Left SCORE
Shoulder Flex/Extend Roll/Turn
UPPER EXTREMITIES

Abd./Add. Sit/Supine
Int. rot./Ext. rot. Scoot/Bridge
Sit/Stand

TRANSFERS
Bed/Wheelchair
Elbow Flex/Extend
Toilet
Forearm Sup./Pron.
Floor
Wrist Flex/Extend
Auto
Fingers Flex/Extend
Static Sitting
Hip Flex/Extend

BALANCE
LOWER EXTREMITIES

Dynamic Sitting
Abd./Add.
Static Standing
Int. rot./Ext. rot.

m
Dynamic Standing
Knee Flex/Extend
Propulsion

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W/C SKILLS
Ankle Plant/Dors
Pressure Reliefs
Foot Inver/Ever
Foot Rests
PL m Locks
M ste
OBJECTIVE DATA TESTS AND SCALES
MANUAL MUSCLE TEST (MMT) MUSCLE STRENGTH FUNCTIONAL RANGE OF MOTION (ROM) SCALE
GRADE DESCRIPTION GRADE DESCRIPTION
SA sy

5 Normal functional strength - against gravity - full resistance.

5 106% active functional motion.
4 Good strength - against gravity with some resistance.
4 75% active functional motion.
3 Fair strength - against gravity - no resistance - safety compromise.
3 50% active functional motion.
n

2 Poor strength - unable to move against gravity.

Trace strength - slight muscle contraction - no motion. 2 25% active functional motion.
1
1 Less than 25%.
.p

0 Zero - no active muscle contraction.

FUNCTIONAL INDEPENDENCE SCALE (bed mobility, transfers, W/C skills) NORMATIVE DATA FOR JOINT MOTION (ROM)
w

GRADE DESCRIPTION AREA ACTION/MOVEMENT

o o
5 Physically able and does task independently. Shoulder Flex 158 Extend 55 o
w

o
4 Verbal cue (VC) only needed. Abd. 170 50
o Add. o
3 Stand-by assist (SBA)-100% patient/client effort. Int. rot. 70 Ext. rot. 90
w

2 Minimum assist (Min A)-75% patient/client effort. 145 o Ext. 0o

Elbow Flex
1 Maximum assist (Max A)-25% - 50% patient/client effort. o
85 Pron. o
70 o
Forearm Sup.
0 Totally dependent-total care/support o
73 Ext. 70
Wrist Flex o o
BALANCE SCALE (sitting - standing) Fingers Flex all 90 Ext. 0
o
GRADE DESCRIPTION Hip Flex 901-115 Ext. 25 o
o o
5 Independent Abd. 45 Add. 30
o
4 Verbal cue (VC) only needed. Int. rot. 45 Ext. rot. 45o
Stand-by assist (SBA)-100% patient/client effort. o
10o
3
Knee Flex 135 Ext.
2 Minimum assist (Min A)-75% patient/client effort. 20
o
Ankle Plant. 50 Dors.
o
1 Maximum assist (Max A)-25% patient/client effort. 20
o

0 Totally dependent for support. Foot Inv. 30 o Ever.

GAIT
ASSISTANCE: SBA Independent
Min. assist Mod.assist Max. assist Unable
FOR RE-EVALUATION USE ONLY:
SURFACES: Level Uneven
Stairs (number/condition) DISTANCE:
IF A PREVIOUS PLAN OF CARE WAS ESTABLISHED, THEN IT WILL:
WEIGHT BEARING STATUS: FWB WBAT PWB TDWB NWB
ASSISTIVE DEVICE(S): Cane Quad cane Crutches Hemi-walker CHANGE
Wheeled walker Walker Other (specify) NOT CHANGE
QUALITY/DEVIATIONS:
PATIENT INFORMATION

PATIENT'S NAME: MED. RECORD #:

THERAPIST'S PHYSICIAN'S
SIGNATURE/TITLE DATE / / SIGNATURE DATE / /
* If no changes made to Initial Plan of care, MD signature no required.
 Cruz & Sanz Health Services, Inc.

PHYSICAL THERAPY
WEEKLY SUMMARY REPORT

ACTIVITIES PERMITTED: Complete Bedrest Bedrest/BRP Transfer Bed/ Chair Up as Tolerated

Full Weightbearing Partial Weightbearing No Weightbearing Independent at Home No Restrictions
Wheel Chair Walker Cane Crutches Hoyer Lift Stair Climbing
Other
MENTALSTATUS: Oriented Forgetful Disoriented Agitated Comatose Depressed Lethargic
Other

HOMEBOUND STATUS Bed bound Severe SOB Ambulates with Assist Uses W/C, Walker, Cane
DUE TO: Up in Chair with max assist Severe Weakness Paralysis Unable to walk

m
Balance/Gait - Unsteady Other
Subjective Comments:

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Specific Safety Issues Addressed:
PL m
M ste
TREATMENT RENDERED (If Pt/CG. instructed. see response below) INSTRUCTED: Pt. C.G
SA sy

Assessment
Therapeutic Exercises
n

Adaptive Equipment
Transfer Training
.p

Gait Training
w

EMS, Ultrasound, Massages, Hot/Cold Pack

Energy Conservation
w

Other
w

PLAN OF CARE: PROBLEM - ACTION/PROGRESS TOWARD GOALS - PT'S/CG's RESPONSE TO TREATMENT/INSTRUCTION

Interdisciplinary Communication: R.N. P.T./P.T.A. O.T./OTA S.L.P. M.S.W. H.H.A. M.D.

Date/Describe:

Next Scheduled Visit Date: Plan for Next Visit:

Additions to Plan of Care

Patient Name
Therapist Name/Signature/Title Date:
 PHYSICAL THERAPY
TRINITY HEALTH SERVICES, INC. REVISIT NOTE
DATE OF SERVICE:
PT ID PERFORMED VIA NAME, DOB, AND ADDRESS TIME IN OUT
VITAL SIGNS: Temperature: Pulse: Regular Irregular Respirations: Regular Irregular
Blood Pressure: Right / Left / Lying Standing Sitting O2 saturation ____ % (when ordered)
PAIN: None Same Improved Worse Origin Location(s)
Duration Intensity 0- 10 Other Relief measures

HOMEBOUND REASON: Needs assistance for all activities Residual weakness TYPE OF VISIT:
Requires assistance to ambulate Confusion, unable to go out of home alone Revisit SOC DATE:
Unable to safely leave home unassisted Severe SOB, SOB upon exertion Revisit and Supervisory Visit
Dependent upon adaptive device(s) Medical restrictions Other (specify) Other (specify)
TREATMENT DIAGNOSIS/PROBLEM AND EXPECTED OUTCOMES:

SIGNS/SYMPTOMS THAT SHOULD BE PRESENT TO WARRANT ADMINISTRATION OF THE TREATMENT:

PHYSICAL THERAPY INTERVENTION/INSTRUCTIONS (Mark all applicable with an ''X''.)

Evaluation (B1) Balance training/activities Management and evaluation of care plan (B12) Teach safe stair climbing skills
Establish/Upgrade home exercise program TENS Pulmonary Physical Therapy (B6) Teach safe/effective use of adaptive/assist
Copy given to patient Ultrasound (B7) Cardiopulmonary PT device (specify)
Copy attached to chart Electrotherapy (B8) Pain Management Other:

m
Patient/Family education Prosthetic training (B9) CPM (specify)
Therapeutic exercise (B2) Preprosthetic training Functional mobility training

E .co
Transfer training (B3) Fabrication of orthotic device (B10) Teach bed mobility skills
Gait training (B5) Muscle re-education (B11) Teach hip safety precautions
Modality used Modality used Modality used
Location
Frequency
Duration
PL m Location
Frequency
Duration
Location
Frequency
Duration
M ste
Intensity Intensity Intensity
Other Other Other

ROM: SAFETY ISSUES

SA sy

STRENGTH: Obstructed pathways

BALANCE: Home environment
MOBILITY/TRANSFER/AMBULATION: Stairs
n

ASSESSMENT/PATIENT'S PROGRESS: Unsteady gait

.p

SKILLED INTERVENTION (OUTCOME): Verbal cues required

Equipment in poor condition
w

Bathroom
Commode
w

Others:
w

CARE PLAN: Reviewed/Revised with patient involvement. TEACHING, TRAINING, RESPONSE TO INSTRUCTIONS:
If revised, specify To Patient To CG Family Other: ______________________
INSTRUCTION ABOUT: Treatment, Equipment Other: ______________________
Need for referral (specify) TEACHING/TRAINING OF

PLAN FOR NEXT VISIT:

PATIENT/FAMILY RESPONSE TO INSTRUCTIONS:
(specify)
DISCHARGE PLANS DISCUSSED WITH: Patient/Family
Care Manager Physician Other (specify) CARE PLAN UPDATED? No Yes (specify, complete Modify Order)
BILLABLE SUPPLIES RECORDED? N/A Yes (specify)

CARE COORDINATION: Physician PT/PTA OT SLP If PT assistant/aide not present, specify date he/she was
MSW SN HHA Other (specify) contacted regarding updated care plan: / /
SIGNATURES/DATES
Complete TIME OUT prior to signing below.
x / / / /
Patient/Caregiver (if applicable, optional if weekly is used) Date Therapist (signature/title) Date
PART 1 - Clinical Record PART 2 - Therapist
PATIENT NAME - Last, First, Middle Initial ID#
 PHYSICAL THERAPY IN DEPTH ASSESSMENT
REAL BEST HOME HEALTH SERVICES, INC.

*This In Depth Assessment is to be completed in its entirety. No revisit note required!

HOMEBOUND REASON:  Needs assistance for all activities  Residual weakness TYPE OF EVALUATION
 Requires assistance to ambulate  Confusion, unable to go out of home alone  13TH VISIT  Supervisory
 Unable to safely leave home unassisted  Severe SOB, SOB upon exertion  19TH VISIT  30 day visit
 Dependent upon adaptive device(s)  Medical restrictions  Other visit:
 Other (specify)____________________________________________________________ Indicate # ______
SOC Date____/____/_____
TREATMENT DIAGNOSIS(ES) / PROBLEMS IDENTIFIED AT START OF CARE

________________________________________________________________________________________________________
________________________________________________________________________________________________________
PRIOR LEVEL OF FUNCTION/ AT THE START OF CARE
ADLs  Independent  Needed assistance  Unable  Equipment used &/or assistance needed: __________________
_______________________________________________________________________________________________________
In-Home Mobility (gait/wheelchair/scooter):  Independent  Needed assistance  Unable  Equipment used &/or
assistance needed:_________________________________________________________________________________________
Community Mobility (gait/wheelchair/scooter):  Independent  Needed assistance  Unable  Equipment used &/or
assistance needed:_________________________________________________________________________________________
CURRENT LEVEL OF FUNCTION
ADLs  Independent  Needed assistance  Unable  Equipment used &/or assistance needed: __________________
________________________________________________________________________________________________________
In-Home Mobility (gait/wheelchair/scooter):  Independent  Needed assistance  Unable  Equipment used &/or
assistance needed:_________________________________________________________________________________________

m
Community Mobility (gait/wheelchair/scooter):  Independent  Needed assistance  Unable  Equipment used: _____
________________________________________________________________________________________________________
LIVING SITUATION

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 Capable  Able  Willing Caregiver available  Limited caregiver support (ability/willingness)  No caregiver available
Home Safety Barriers:  Clutter  Throw rugs  Needs Grab Bars  Needs railings
 Steps (number/condition)_______________  Other(specify)__________________________________________________
PL mBEHAVIOR/MENTAL STATUS
 Alert  Oriented  Cooperative  Confused  Memory deficits  Impaired judgment  Other (specify)__________
________________________________________________________________________________________________________
M ste
CCURRENT PAIN
Location(s) ________________________________________________________________
Pain (describe) ______________________________________________________________
SA sy

Impact on
Function_____________________________________________________________________
1 2 3 4 5 6 7 8 9 10 Previous Pain Level ____________________________________________________________
n
.p

CURRENT ADL/IADLs
CURRENT MUSCLE STRENGTH/FUNCTIONAL ROM EVAL CURRENT FUNCTIONAL INDEPENDENCE/BALANCE EVAL
w

AREA STRENGTH ACTION ROM TASK LEVEL ASSISTIVE

(degrees) OF DEVICES/
w

ASSIST COMMENTS
RIGHT LEFT RIGHT LEFT Bed Roll/Turn
w

Mobility
Shoulder Flex/Extend Sit/Supine
Abd. /Add. Scoot /Bridge
Int.rot/Ext rot. Transfers Sit/Stand
Elbow Flex/Extend Bed/Wheelchair
Forearm Sup./Pron Toilet
Wrist Flex/Extend Floor
Fingers Flex/Extend Auto
Flex/Extend
Hip Abd. /Add. Balance Static Sitting
Int.rot/Ext rot Static Standing
Knee Flex/Extend Dynamic Sitting
Ankle Plants. /Dors. Dynamic Standing
Foot Inver/Ever Wheel Propulsion
Chair Pressure Reliefs
Skills Foot Rests
Locks
Wheel Chair
Mobility

PATIENT/CLIENT NAME - Last, First, Middle Initial ID#

 MANUAL MUSCLE TEST (MMT) MUSCLE STRENGTH
GRADE GRADE
5 Normal functional strength – against gravity - full resistance.
4 Good strength - against gravity with some resistance
3 Fair strength - against gravity - no resistance – safety
compromise.
2 Poor strength - unable to move against gravity.
1 Trace strength - slight muscle contraction - no motion.

Noted Deviations from previous assessments

GAIT:
Braces/prosthesis:_________________________________________________________
Assistance:  Independent  SBA  Min Assist  Mod Assist  Max Assist  Unable
Distance: _________________ Surfaces:  Level  Uneven  Stairs (number/condition) ______________________________________
Weight Bearing Status:  FWB  WBAT  PWB  TDWB  NWB  Other:_________
Patient Has Assistive Device(s):  Standard Cane  Quad Cane  Crutches  Wheel Chair
 Walker(specify type) ________________  Other (specify) ___________________________________________________
Patient Needs Assistive Device(s):  Standard Cane  Quad Cane  Crutches  Wheel Chair
 Walker(specify type) ________________  Other (specify) Noted Gait Deviations: _________________________________
_______________________________________________________________________________________________________
Balance: TUG (On a scale of 1-4) 1  Less than 10 seconds - High mobility 2  10-19 seconds -Typical mobility
3  20-29 seconds - Slower mobility 4  30+ seconds - Diminished mobility: Interventions: __________________
BERG or Tinnetti Forms can be attached if appropriate for evaluation
Sensation (describe & include impact on function if appropriate):

m
REHAB POTENTIAL/ DISCHARGE PLANS

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Rehab Potential Fair: Pt will develop
functional mobility within the home care
setting
Rehab Potential: Good with PT able to PL m
return to previous level of activity and
improvement in functional status in
M ste
accordance with pt's endurance level.
Discharge Plan: Pt will be d/c when Pt is
able to function independently w/in current
limitations @ home
SA sy
Rehab Potential: Guarded with minimal
improvement in functional status expected
and decline is possible.
Rehab Potential: Good for PT to be able
to follow the plan of care/treatment
regimen, and be able to self manage
her/his condition.
Other
Rehab Potential: good for stated
goals
Discharge Plan: Pt will be discharged
when Pt is able to function with
assistance of caregiver within current
limitations at home
Other

Current Goals that pertain to current illness Progress Toward Goals/ Lack of Progress Toward Goals
Pt. will ______ assist with bed mobility within_____
n

 weeks  visits.
.p

Pt. to demonstrate increased strength of ________ (include

specific joint, muscle, and indicate left, right or bilat.) to
_______ within ______  weeks  visits
w

Pt. &/or cg will demonstrate comprehension of home

exercise program within____  weeks  visits.
w

Pt will verbalize pain relief from ___/10 to ____/10 within

____________  weeks  visits.
w

Pt. will demonstrate increased ___ ROM of ______ to

______ degrees within ______  weeks  visits
Pt/cg will demonstrate __________transfers with ______
level of assist within____  weeks  visits.
Pt will ambulate _____ feet with ____________assistance
 with  without ___________________assistive device
within __________  weeks  visits
Increase ______ sitting balance to _______ within ______
 weeks  visits
Increase ______ standing balance to _______ within _____
 weeks  visits
Additional Current Goals Progress Toward Goals/ Lack of Progress Toward Goals
Other:
Other:
Other:

PATIENT/CLIENT NAME - Last, First, Middle Initial ID#

New Goals: Functional Reassessment Expectation of Progress Toward Goals

If lack of progress to goals: therapist and physician determination of need for continuation

Supportable statement to continue therapy and why goals attainable:

Safety (PT to document noted safety concerns and the training needed to address them):

m
Treatment Provided This Visit:

E .co
PL m
M ste
Plan for next visit:
SA sy
n

Patient/Caregiver response to Plan of Care:

.p
w

Care coordination/ interdisciplinary communication ( to address findings and plans to continue) with:  Physician  SN
w

 Case Manager  PTA  OT  ST  MSW  Other (specify)______________________________________________

w

Changes to the POC:

Patient/Client Signature___________________________ Therapist Signature/Title _________________________________

Date ____/____ / _____Time In ________ Time Out_______ Date_____/_____/_______ QI Review  Yes Frequency Verified 
Yes

PATIENT/CLIENT NAME - Last, First, Middle Initial ID#

 PHYSICAL THERAPY VISIT NOTE
VISIT DATE: / /

VITAL SIGNS: Pulse: Regular Irregular Respiration: Regular Irregular

Blood Pressure: Right / Left / Lying Standing Sitting
PAIN: None Same Improved Worse
Location(s) NO HURT HURTS HURTS HURTS HURTS HURTS
LITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORSE
Frequency: Constant Intermittent Occasional Intensity 1 - 1 0
.
Relief Measures 0 2 4 6 8 10
N o Pain Moderate Pain Worst Possible Pain

HOMEBOUND REASON: Needs assistance for all activities Residual weakness TYPE OF VISIT:
Requires assistance to ambulate Confusion, unable to go out of home alone Evaluation Visit
Requires assistance to transfer Severe SOB, SOB upon exertion Visit and supervisory visit
Unable to safely leave home unassisted Medical restrictions Discharge
Dependant upon adaptive device(s) Other (specify) Other (specify)

TREATMENT DIAGNOSIS/PROBLEM

INTERVENTIONS

m
Evaluation Gait training Pain Management
CPM (Specify)
Establish rehab. program Home exercise program upgrade Functionality Mobility Training

E .co
Establish home exercise program Pulmonary Physical Therapy Teach safe/effective use of adaptive/
Copy given to patient assist device (specify)
Copy attached to chart Disease Process and Management Teach safe stair climbing skills
Patient/Client/Family education Energy Conservation Techniques Teach Bed mobility skills
Therapeutic/Isometric/Isotonic Exercises
Muscle Strengthening
PL m Prosthetic Training
Teach hip safety precautions
Falls Prevention
Body Mechanics/Posture Training
M ste
Preprosthetic Training
Passive/Active/Resistive exercises Pulse Ox
Stretching exercises Management and Evaluation of Care Plan Other:
Transfer Training Muscle/Neuro Re-Education
SA sy

Balance training/activities Breathing/CP Conditioning Exercises

Note: Specify location, amount, frequency and duration with any modality SAFETY ISSUES
n

ASSESSMENT/PROGRESS TOWARDS GOALS: Obstructive pathways

Home environment
.p

Stairs
Unsteady gait
w

Verbal cues required

ROM: Equipment in poor condition
w

STRENGTH: Bathroom
w

BALANCE: Impaired judgement/safety

AMBULATION: Other (specify)

TRANSFERS/BED MOBILITY:
PATIENT/CAREGIVER RESPONSE:
PLAN FOR NEXT VISIT: SUPERVISORY VISIT (Complete if applicable)

PT Assistant Aide Present Not present N/A

Supervisory Visit: Scheduled Unscheduled
DISCHARGE PLANS DISCUSSED WITH: Observation of
Patient/Family/Caregiver Care Manager Physician
Other (specify) Teaching/Training of

CARE COORDINATION: None Physician PT/PTA

Patient/Family Feedback on Services/Care (specify)
OT SLP MSW SN HHA Case Manager
Other (specify)
Care Plan Updated? No Yes (specify)

MEDICATION CHANGE. Since last visit Yes No

SIGNATURE/DATE:

x / /
Therapist (signature/title) Date

PATIENT NAME - Last, First, Middle Initial ID#

 PHYSICAL THERAPY EVALUATION

DATE OF SERVICE / /
OBJECTIVE DATA TESTS AND SCALES PRINTED ON NEXT PAGE
HOMEBOUND REASON: Needs assistance for all activities Residual weakness SOC DATE / /
Requires assistance to ambulate Confusion, unable to go out of home alone (If Initial Evaluation, Complete Physical
Unable to safely leave home unassisted Severe SOB, SOB upon exertion Therapy Care Plan)
Dependent upon adaptive device(s) Medical restrictions OTHER DISCIPLINES PROVIDING CARE:
Other (specify) Requires assistance to transfer SN OT ST MSW Aide
PERTINENT BACKGROUND INFORMATION
PT ORDERS: Evaluation Therapeutic Exercise Transfer Training Home Program Instruction Gait Training Chest Pt.
Ultrasound Electrotherapy Prosthetic Training Muscle Re-education Other:
TREATMENT/DIAGNOSIS/PROBLEM:

MEDICAL HISTORY REASON FOR EVALUATION (Diagnosis/Problem/History)

Hypertension Cancer Immunosuppressed
Cardiac Arthritis
Diabetes Other (specify)
Respiratory
Osteoporosis

m
Fractures

E .co
Capable Able
LIVING SITUATION
Willing caregiver available ALF
PL m
M ste
Limited caregiver support (ability/willingness) PRIOR LEVEL OF FUNCTION
No caregiver available
ADLs: Independent Level of assistance _________ Unable
HOME SAFETY BARRIERS:
SA sy

Equipment Used:
None Clutter Throw rugs Bath bench/equipment Other:
Needs grab bar Needs railings Steps (number/condition) IN-HOME MOBILITY (gait or wheelchair/scooter):
n

Other (specify) Independent Level of assistance ________________ Unable

.p

Equipment Used: No AD Cane/QC Walker/RW WC/Scooter

Other:
w

BEHAVIOR/MENTAL STATUS
Alert TRANSFER MOBILITY:
Oriented ___x1___ x2___ x3 Cooperative
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Independent Level of assistance ________________ Unable

Confused Memory deficits Impaired judgement
Equipment Used: No AD Cane/QC Walker/RW WC/Scooter
w

Other (specify)
Other:
COMMUNITY MOBILITY (gait or wheelchair/scooter):
Independent Level of assistance ____________ Unable
PAIN
Equipment Used: No AD Cane/QC Walker/RW WC/Scooter
Other:
VITAL SIGNS/CURRENT STATUS

HURTS HURTS
Blood Pressure:
NO HURT HURTS HURTS HURTS
LITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORSE Pulse:
6 8
Respirations:
0 2 4 10
Skin Condition:
LOCATION: Edema:
FREQUENCY: Occasional Intermittent Continuous Vision:
Sensation:
AGGRAVATING/RELIEVING FACTORS:
Communication:
Hearing:
Posture:
Activity Tolerance:
Muscle Tone:
Orthotic/Prosthetic devices:
PATIENT NAME - Last, First, Middle Initial ID#

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 PHYSICAL THERAPY EVALUATION (Cont'd)
MUSCLE STRENGTH / FUNCTIONAL ROM EVAL FUNCTIONAL INDEPENDENCE/BALANCE EVAL

BED MOBILITY
STRENGTH ROM TASKS ASSIST SCORE ASSISTIVE DEVICES/COMMENTS
UPPER EXTREM.

AREA AREA
Right Left Right Roll/Turn
Left

Shoulder Flex/Extend Sit/Supine

Abd/Add. Scoot/Bridge
Int. Rot./Ext. Rot. Sit/Stand

TRANSFERS
Elbow Flex/Extend Bed/Wheelchair
Forearm Sup./Pron. Toilet
Wrist Flex/Extend Floor
Fingers
LOWER EXTREM.

Flex/Extend Auto
Hip Flex/Extend Static Sitting

BALANCE
Abd./Add. Dynamic Sitting
Int. Rot./Ext. Rot. Static Standing
Knee Flex/Extend Dynamic Standing
Ankle Plant./Dors. Propulsion

W/C SKILLS
Foot Inver./Ever. Pressure Reliefs
SPINE

AREA STRENGTH ACTION ROM Foot Rests

m
Locks
MANUAL MUSCLE TEST (MMT) MUSCLE STRENGTH FUNCTIONAL INDEPENDENCE SCALE (bed mobility, transfers, balance, W/C Skills)

E .co
GRADE DESCRIPTION
5 Normal functional strength - against gravity - full resistance
4 Good strength - against gravity with some resistancePL m
3 Fair strength - against gravity - no resistance - safety compromise
M ste
2 Poor strength - unable to move against gravity
1 Trace strength - slight muscle contraction - no motion
0 Zero - no active muscle contraction
SA sy
GRADE DESCRIPTION
6 Independent - physically able and independent
5 Supervision and/or verbal cues - 100% patient effort
4 Contact guard - 100% patient effort
3 Minimum assist (Min A) - 75% patient/client effort
2 Moderate assist (Mod A) - 50% patient effort
1 Maximum assist (Max A) - 25%-50% patient/client effort
0 Totally dependent - total care/support

FUNCTIONAL RANGE OF MOTION (ROM) SCALE SAFETY ISSUES

GRADE DESCRIPTION GRADE DESCRIPTION Obstructive pathways Equipment in poor condition
Home environment
n

5 100% active functional motion 2 25% active function motion Bathroom

Stairs Impaired judgement/safety
.p

4 75% active functional motion 1 Less than 25% Unsteady gait Other (specify)
3 50% active functional motion Verbal cues required
w

GAIT
w

ASSISTANCE: Independent SBA Contact guard Minimum assist Moderate assist Maximum assist Unable
SURFACES: Level Uneven Stairs (number/condition) DISTANCE/TIME:
w

WEIGHT BEARING STATUS: FWB WBAT PWB TTWB NWB

ASSISTIVE DEVICE(S): Cane Quad Cane Crutches Hemi Walker Walker Wheeled Walker
Other (specify):

QUALITY/DEVIATIONS/POSTURES:

SUMMARY
INSTRUCTION PROVIDED: Safety Exercise Other (describe)
Equipment needed (describe)

DISCHARGE DISCUSSED WITH: Patient/Family Care Manager Physician APPROXIMATE NEXT VISIT DATE: / /
Other (specify) PLAN FOR NEXT VISIT

CARE COORDINATION: None Physician SN PT OT ST

MSW PTA COTA Aide Case Manager
Other (specify)

x x / /
Therapist Printed Name and Title Therapist (signature) Date
 PHYSICAL THERAPY
CARE PLAN
Diagnosis: SOC DATE / /
FREQUENCY AND DURATION:
Patient/Caregiver aware and agreeable to POC and Frequency Duration: Yes No (explain)
INTERVENTIONS
Evaluation Gait training Pain Management
CPM (Specify)
Establish rehab. program Home exercise program upgrade Functionality Mobility Training
Establish home exercise program Pulmonary Physical Therapy Teach safe/effective use of adaptive/
Copy given to patient assist device (specify)
Copy attached to chart Disease Process and Management Teach safe stair climbing skills
Patient/Client/Family education Energy Conservation Techniques Teach Bed mobility skills
Teach hip safety precautions
Therapeutic/Isometric/Isotonic Exercises Prosthetic Training Falls Prevention
Muscle Strengthening Body Mechanics/Posture Training
Preprosthetic Training
Passive/Active/Resistive exercises Pulse Ox
Stretching exercises Management and Evaluation of Care Plan Other:
Transfer Training Muscle/Neuro Re-Education
Balance training/activities Breathing/CP Conditioning Exercises
Monitor Vital Signs: PROVIDE:
U.S. to _______________________________________________ at _______________ warts/cm2 x ___________ minutes.

m
Pulse EMS to _____________________________________________________________ x ______________ minutes.
Blood Pressure Heat/Cold to _____________________________________________________________ x _______________ minutes.

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Therapeutic massage to ___________________________________________________ x ________________ minutes.
Respirations Joint Mobilization __________________________________________________________________________________

SHORT TERM GOALS

Demonstrate effective pain management within
PL m weeks
LONG TERM GOALS

Return to pre-injury/illness level of function within weeks

M ste
Improve bed mobility to assist within weeks
Patient will meet maximum rehab potential within weeks
Improve transfers to assist using
Return to optimal and safe functionality within weeks
within weeks
SA sy

Decrease pain level to within weeks

Decrease pain level to within weeks
Patient to be independent with safety issues in weeks Improve bed mobility to assist within weeks
n

Improve wheelchair use to within weeks Improve transfers to assist using

within weeks
.p

Patient will ambulate with device with assist

within weeks Patient to be independent with safety issues in weeks
w

Patient will be able to climb stairs/uneven surfaces Improve wheelchair use to within weeks
with device with assist within weeks Patient will ambulate with device with assist
w

within weeks
Ambulation distance will be minutes or feet
within weeks Patient will be able to climb stairs/uneven surfaces
w

Increase strength of R L UE to with device with assist within weeks

/5 in weeks
Increase strength of R L LE to Ambulation endurance will be minutes or feet
/5 in weeks
within weeks
Improve strength of to /5 within weeks
Increase strength of R L UE to /5 in weeks
Increase ROM of joint to degree flexion
Increase strength of R L LE to /5 in weeks
and degree extension in weeks
Improve strength of to /5 within weeks
Increase ROM of joint to degree
Increase ROM of joint to degree flexion
Of in weeks and degree extension in weeks
Demonstrate ROM to WNL within weeks Increase ROM of joint to degree
Improve balance to in weeks of in weeks
Other Demonstrate ROM to WNL within weeks
Improve balance to in weeks
Other
GOALS: PHYSICAL THERAPY
REHAB POTENTIAL: Poor Fair Good Other
DISCHARGE PLAN: Patient will be discharged to care of self/caregiver with self/caregiver arranged healthcare
Other
ADDITIONAL INFORMATION:
PTA is following the case
Plan developed by (Name/Signature/Title) Date
PATIENT NAME - Last, First, Middle Initial ID#
 THERAPY DISCHARGE SUMMARY
PATIENT LAST NAME FIRST NAME PATIENT #

TYPE OF DISCHARGE: COMPLETE PARTIAL - STILL RECEIVING SERVICES OF: PT ST OT HHA SN

ADM DATE DISCH DATE DR

DIAGNOSIS (PRIMARY) ADDRESS

CITY, ST ZIP

VISITS RENDERED BY: RN HHA PT OT ST MSW

REASON FOR DISCHARGE: GOALS MET MOVED OUT OF AREA OTHER
HOSPITALIZATION PATIENT EXPIRED
SKILLED NURSING FACILITY CARE REFUSED
TRANSFER TO ANOTHER AGENCY SKILLED CARE NO LONGER NEEDED
DISPOSITION SELF CARE NH ACLF FAMILY CARE OTHER
CONDITION IMPROVED STABLE UNSTABLE DECEASED REGRESSED
DEPENDENT INDEPENDENT REQUIRES SUPERVISION/ASSIST

m
DEPENDENCY
EXERCISES PASSIVE ACTIVE ACTIVE ASSISTIVE RESISTIVE

E .co
PERFORMED WITH: R.U.E. R.L.E. L.U.E. L.L.E. TRUNK NECK
TRANSFER HOYER LIFT CRUTCHES WALKER
ACTIVITIES: W/C CANE QUAD CANE OTHER
GAIT TRAINING: N.W.B.
EVEN SURFACES
PL m
P.W.B.
STAIRS
F.W.B.
UNEVEN SURFACES
M ste
ASSISTANCE
REQUIRED: MAXIMUM MINIMUM MODERATE GUARDING OTHER
DISTANCE
SA sy

AMBULATED: 20 ft. 40 ft. 60 ft. 80 ft. 100 ft. 120 ft.

INSTRUCTED ON
n

HOME PROGRAM: PATIENT SIGNIFICANT OTHER FAMILY

.p

NARRATIVE:
w
w

SUMMATION OF SERVICES RENDERED AND GOALS ACHIEVED

Physical Therapy
PATIENT HAS ACHIEVED ANTICIPATED GOALS DEMONSTRATES TRANSFER TECHNIQUE AND USE OF SPECIAL
w

PATIENT IS SAFELY INDEPENDENT WITHIN DISEASE LIMITATIONS DEVICES

ABSENCE OF PAIN DEMONSTRATES ABILITY TO DO SPECIAL TREATMENTS

FREE OF CONTRACTURES HEALED INCISION

RANGE OF MOTION OF ALL JOINTS IS WITHIN NORMAL RANGE DEMONSTRATES STUMP WRAPPING AND HYGIENE
DEMONSTRATES RANGE OF MOTION EXERCISES DEMONSTRATES TECHNIQUE TO CARE FOR AND PROTECT
FUNCTIONING EXTREMITY
DEMONSTRATES MUSCLE STRENGTHENING EXERCISES
DESCRIBES PHANTOM LIMB SENSATION
DEMONSTRATES TURNING AND POSITIONING SCHEDULE
PATIENT DEMONSTRATES STABILIZATION OF AMBULATION
AMBULATES SAFELY WITH ASSISTIVE DEVICE
AMBULATES SAFELY WITHOUT ASSISTIVE DEVICE Occupational Therapy
PATIENT HAS REACHED ALL REALISTIC ACHIEVABLE GOALS
Speech Therapy DEMONSTRATES KNOWLEDGE OF OPERATION & CARE OF
PATIENT HAS REACHED ALL REALISTIC ACHIEVABLE GOALS ADAPTIVE EQUIPMENT
PATIENT HAS ATTAINED MAXIMUM BENEFIT FROM THERAPEUTIC
DEMONSTRATES ENERGY CONSERVATION/WORK SIMPLIFICATION
PROGRAM TECHNIQUES
VERBAL AND SENTENCE FORMULATION AND COMPREHENSION DEMONSTRATIONS COMPENSATORY & SAFETY TECHNIQUES
IMPROVED TO MAXIMUM ATTAINMENT WITHIN DISEASE LIMITATIONS

PATIENT/S.O. RESPONSE AND ADHERENCE TO TEACHING: GOOD FAIR POOR

THERAPY GOALS MET: YES NO IF NO, EXPLAIN

PATIENT/S.O.GOALS MET: YES NO IF NO, EXPLAIN

COMMENTS:

PATIENTS/So. INSTRUCTED ON IMPORTANCE OF ADHERENCE OF EXERCISE PROGRAM, M.D. FOLLOW-UP AND NOTIFY M.D. IF COMPLICATIONS OCCUR. M.D. NOTIFIED OF DISCHARGE

THERAPIST SIGNATURE DATE

White: Medical Records Yellow: Physician
 Visit made
PHYSICAL THERAPY DISCHARGE SUMMARY No visit
PATIENT TO: DR.
CR# HIC# ADDRESS
SOC 1st VISIT CITY ZIP
D/C DATE COMPLETE or PARTIAL - continued services
REASON FOR DISCHARGE:
NUMBER OF VISITS: PT OT SLP MSS AIDE
DIAGNOSES:
ADMISSION STATUS DISCHARGE STATUS
Pain due to , level Pain due to , level
ROM ROM
Strength and Endurance Str/End
Balance Balance
Coordination Coordination

m
Bed Mobility Bed Mobility
Transfers Transfers

E .co
Ambulation Ambulation
Fine Motor Coordination Fine Motor Coord
Sensory/ Perceptual Awareness PL m S/P Awareness
Sensory/Perceptual Coordination S/P Coord
Receptive Communication Receptive Com
M ste
Expressive Communication Expressive Com
Swallowing Swallowing
SA sy

Knowledge level of Knowledge level of

Disease Process Disease Process
n

HEP HEP
Treatments Treatments
.p

Care Management Care Management

w

Safety Safety
Other Other
w

Other Other
w

PROBLEMS IDENTIFIED AFTER START OF CARE:

SELF CARE ACTIVITY ON ADMISSION:

At d/c: Self Care resumed; or Assist to be provided by I

or Transferred to
CARE PROVIDED: Observation/Evaluation, Instruction, Personal care as ordered,
Treatments as ordered, Other

UNMET NEEDS:

INSTRUCTIONS FOR CONTINUING CARE NEEDS: Equipment management, Physician follow-up,

Home program, Other

ADDITIONAL COMMENTS/ Referrals made:

__

Physician contacted on and discharge is approved.

Therapist Signature Date

 PHYSICAL THERAPY
DISCHARGE SUMMARY ADDENDUM
PHYSICAL THERAPY GOALS REACHED
MAINTAIN/COMPLY WITH HOME SAFETY PROGRAM
POC (485) GOALS REACHED:
PATIENT AMBULATED WITH __________________ (device) FOR
PATIENT DEMONSTRATED CORRECT BODY MECHANICS
_____________ FT WITH ________ ASSIST
PATIENT AND/OR CG COMPREHEND AND DEMONSTRATED
HOME EXERCISE PROGRAM INCREASED STRENGTH OF RUE LUE RLE LLE
TO ALLOW PATIENT TO PERFORM THE FOLLOWING
ABLE TO COMPLY WITH EXERCISES: BOTH PASSIVE AND ACTIVITIES: _______________________________________.
ACTIVE EXERCISE REGIMEN
INCREASED RANGE OF MOTION (ROM) OF
DEMONSTRATED EFFECTIVE FALL PREVENTION __________________ JOINT TO ________ DEGREE
PROGRAM FLEXION AND ______ DEGREE EXTENSION IN ____
WEEKS TO ALLOW PATIENT TO PERFORM THE
IMPROVED THE USE OF ASSISTIVE DEVICE: ________________ FOLLOWING ACTIVITY: ____________________________.

CARE PLAN SHORT/LONG TERM GOALS REACHED: MUSCLE STRENGTH

Pt. able to hold weigh _______ lb
GENERAL
Pt. able to oppose flexion or extension force over _____
Gait increased tinetti gait score to _____ / 12
Improved gait requiring ____ to _____ from _____ to ______ PAIN
Pain decreased from _______/10 to ________ /10
BED MOBILITY
DEMONSTRATED EFFECTIVE PAIN MANAGEMENT

m
Pt. able to turn side (facing up) to lateral (left/right)
PATIENT EXPERIENCED A DECREASE IN PAIN
Pt. able to lie back down

E .co
ROM
Pt. able to sit up independently _______
Pt. increased ROM of ________ by ______ degrees
Pt. able to self reposition flexion/extension
IMPROVED BED MOBILITY (INDEPENDENT)
BALANCE
PL m SAFETY
Pt. able to use ________________ independently to ________ feet
Increased tinetti balance score to _____/16
M ste
Pt. able to self propel wheel chair _________ feet
Pt. able to reach steady static/dynamic sitting/standing balance
with/without assistance Pt able to finalize and demonstrated to follow up HEP.
SA sy

TRANSFER OTHER:
Pt. able to transfer from _________ to _________ with/without assistance
n

INDEPENDENT WITH TRANSFER SKILLS

.p

STAIR/UNEVEN SURFACE
Pt. able to climb stair/uneven surface with/without assistance _____ steps #
w

_______
w

ADDITIONAL SPECIFIC THERAPY GOALS REACHED

w

Patient Expectation SHORT TERM LONG TERM

DISCHARGED: PATIENT AND/OR CAREGIVER IS/ARE ABLE TO DEMONSTRATE KNOWLEDGE

DISCHARGE INSTRUCTIONS DISCUSSED WITH: Patient/Family
OF DISEASE MANAGEMENT, S/S COMPLICATIONS.
Care Manager Physician Other (specify) PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HIS/HER CURRENT LIMITATION AT HOME.
CARE WAS COORDINATED: Physician OT SN ST RETURNED TO INDEPENDENT LEVEL OF SELF CARE.
MSW Aide PTA Other (specify) ABLE TO REMAIN SAFELY IN RESIDENCE WITH ASSISTANT OF ________________________

REHAB STATUS: Poor Fair Good Excellent

ABLE TO REMAIN IN HOME/RESIDENCE/ALF WITH ASSISTANCE OF PRIMARY CAEGIVER/SUPPORT AT HOME
DISCHARGED: MAXIMUM FUNCTIONAL POTENTIAL REACHED
ABLE TO UNDERSTAND MEDICATION REGIMEN, AND CARE RELATED TO HIS/HER DISEASE.
DISCHARGED: MAXIMUM FUNCTIONAL POTENTIAL REACHED.
ABLE TO UNDERSTAND MEDICATION REGIME AND CARE RELATED TO DISEASE

Goals documented by: Date

Therapist Name/Signature/title

PATIENT NAME - Last, First, Middle Initial ID#

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