Physical Therapy Plan of Treatment

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Joanna Webster
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1 Caring for Your Quality of Life Physical Therapy Plan of Treatment SOC Date Clinical Interview Relevant Background Information The Interview was completed With: Patient Spouse Caregiver Other: _ Patient Age: Years Mental Status: Alert Oriented x Impaired: The patient resides in a: Home Apartment/Condo ILF ALF or Other: Barriers: The patient lives: Alone or with Spouse Family 24 Hour Care Giver or Other: Who currently helps with ADLs? Reason for Referral/Symptom Onset Prior Level of Function Independent or Required Assistance (Describe) Current Level of Function (Summary from PT Evaluation) Assistive Device History Prior to the onset of the current condition, the patient utilized (List adaptive equipment used): Currently, the patient utilizes: Comments: (Address safety and effective use of equipment): Fall History & Risk Patient has had fall(s). The last fall occurred on (date): Location: which resulted in (Describe injury or condition): Patient is at risk for falls due to: Loss of balance Poor postural alignment/control Difficulty walking Freezing when walking Is patient able to call for help? Yes No Comments: Rehabilitation History No prior therapy (PT, OT, SLP) appears to have been provided in the past 12 months or The patient has received PT OT SLP in the last 12 months for the current or a previous condition Describe: The patient is not currently receiving home health services PT Plan of Treatment Page 1 of 2 Revised: 03/2010

2 Patient s Last Name First Name HICN: Medical History/Medications (Describe all relevant medical conditions and the date of onset. Include psychosocial diagnosis(es) if present) Precautions/Contraindications (For a specific activity and/or intensity of rehabilitation services) Physical Therapy Plan of Treatment Treatment Plan: Physical Therapy days/wk x weeks for a treatment duration of hours per visit Initial Certification Period: From: - To: Rehabilitation Potential: Guarded Fair Good Excellent Long Term Goals (Number Each Goal): Skilled Intervention to Include: Therapeutic Exercise Neuromuscular Re-Education Gait Training Manual Therapy Wheelchair Training Prosthetic Training Other: Additional Recommendations: OT Evaluation Speech/Language Evaluation Social Services Adaptive Equipment: Medical Follow-Up For: Other: Professionals Establishing This Plan of Treatment Therapist s Name & Credentials (Please Print) Therapist s Signature Date X As of the date of this evaluation, I certify the pertinent medical history and the need for skilled services that have been completed in consultation with the evaluating therapist under this plan. Physician s Name (Please Print) Physician s Signature Date X PT Plan of Treatment Page 2 of 2 Revised 03/2010

3 Caring for Your Quality of Life g Physical Therapy Initial Evaluation SOC Date Clinical Evaluation Range of Motion Grossly WFL or Impaired (Check All Areas of Impairment) Cervical Spine Lumbar Spine ROM Measurements: Left UE Right UE Left LE Right LE Muscle Strength Grossly WFL or Impaired (Check All Areas of Impairment) Cervical Spine Lumbar Spine MMT Measurements: Left UE Right UE Left LE Right LE Muscle Tone Grossly WFL or Impaired (Describe Area & Level of Impairment Using Modified Ashworth Scale 0-4) Sensation Grossly WFL or Impaired (Describe Below) Edema Not Present or Present (Describe Below) Pain Not Present or Present (Describe using a 0-10 Visual Analog Scale (VAS) Endurance Good Fair Poor (Describe Level of Endurance) Gait/Posture Analysis Tests Administered: Tinetti Gait/Balance Berg Balance Scale Functional Reach Test (Attach Results) Posture Grossly WFL or Impaired Gait Grossly WFL or Impaired (Describe gait pattern, safety and tolerance) Ambulation Tolerance: PT Evaluation Page 1 of 2 Revised 03/10

4 Patient s Last Name First Name HICN: Functional Evaluation ance: I=Independent S=Stand-By/Supervision Min=25% Mod=50% Max=75% Total=100% Functional Task Prior LOF Current Level of Function (LOF) Goal LOF Balance: Sitting Balance: Standing Balance: Dynamic Transfer Bed/Chair Transfer Chair/Stand Bed Mobility Other: NT N/A NT N/A NT N/A NT N/A NT N/A NT N/A NT N/A Other Pertinent Findings: OPTIMAL Instrument Activity 1. Lying Flat 2. Rolling Over 3. Moving- Lying to Sitting 4. Sitting 5. Squatting 6. Bending/Stooping 7. Balancing 8. ling 9. Walking Short Distance 10. Walking Outdoors 11. Climbing Stairs 12. Pushing 13. Pulling 14. Lifting 15. Carrying Level of Difficulty (Score) Prior LOF Current LOF Goal LOF OPTIMAL Scoring Guide 0 = Not Applicable (N/A) 1 = Performed without Difficulty 2= With Little Difficulty 3 = Moderate Difficulty 4 = Very Difficult 5 = Unable to Do From the OPTIMAL Instrument, which 3 activities would the Patient MOST like to perform? Total Score: /75 /75 /75 On a 0 10 Scale, place an X on the Patient s overall level of confidence in performing daily functional tasks Not at all Very Confident Confident PT Evaluation Page 2 of 2 Revised: 03/10

5 Evaluation Note Caring for Your Quality of Life SOC/Eval Date Billing & Coding Summary Intake Information 0 UNITS The patient was seen today for an initial therapy evaluation. The Plan of Treatment was developed and skilled therapy will be initiated after the Plan of Treatment has been reviewed and signed by the appropriate physician PT Evaluation OT Evaluation Evaluation / Swallow Evaluation / Speech, Language, Voice TOTAL TIME (MIN) TOTAL UNITS Time Spent for Care: Time In: AM / PM Time Out: AM/PM Patient Certification: I certify that I was seen by the therapist below and agree that the time spent for my care is correct. I understand and agree to the goals and plan of care developed. I certify that I am not receiving home health services at this time. Patient/Authorized Representative (Please Print) Provider: Therapist s Name & Credentials (Please Print) Patient/Authorized Signature X Therapist s Signature X Evaluation Note Page 1 of 1 Revised: 03/2010

Provider No Onset Date SOC Date. Clinical Interview

Provider No Onset Date SOC Date. Clinical Interview Plan of Treatment Provider No Onset SOC Clinical Interview The Interview was completed with: Patient Spouse Caregiver Other: Patient Age: Years Mental Status: Alert Oriented x Impaired: Living Situation