INITIAL PHYSICAL THERAPY EVALUATION AND CARE PLAN
Patient Name: ______Date: ___ /____ /_____ Time: In_____ am/pm Out ____ am/pm

Agency Name: ______DOB: ____ /_____ /____ Male Female
Significant Medical History/Clinical Findings
Primary Dx: ______ Onset Date__ /__ /___

Past Medical History: ______
______

Prior Level of Function: (I=Independent; D= Dependent)
I D Community Gait No assistive Device IADL and ADL
I D Limited Community Gait Used Walker IADL only
I D Household Gait Used Cane Dependent ADL
I D Limited Household Gait Used wheelchair Other Limitations

Mental Status:
Oriented Forgetful Disoriented Agitated Comatose Depressed Lethargic
Other: (skin, edema, sensation, coordination)______
______
Vitals: Pulse_____/min BP_____/_____ RR_____/min Shortness of breath when ambulate>20 ft __ yes__ no
Pain Assessment:
Intensity: None 0 1 2 3 4 5 6 7 8 9 10 Severe Location:______
Increases with:
Decreases with:
Description: Intermittent Constant Dull Sharp Pain management plan established: __ Yes __ No___


Pain Relief Measures: ______

Patient Stated Goals: ______

ROM: Neck/Trunk: WNL RUE WNL LUE WNL RLE WNL LLE WNL

Limitations:


Strength: Neck/Trunk: WNL RUE WNL LUE WNL RLE WNL LLE WNL

Limitations:

Muscle tone: __Normal__ abnormal Specify______
Has the patient fallen in the past 12 months or since the last assessment? ___ Yes ___ No


Coordination: ______Sensation: ______

Patient Name: ______Date: _____/______/_____

Functional Assessment:

Current Functional Status / Prior Functional Status
Functional Assessment / Ind / Sup / CG / Min / Mod / Max / Dep / NA / Ind / Sup / CG / Min / Mod / Max / Dep / NA
Bed mobility
Supine to sit
Transfer i/o of bed
Bed to chair
Sit to stand
Toilet/commode
Shower/tub transfer
Orthosis/prosthesis
Ambulation / Ind / Sup / VC / CG / Min / Mod / Max / A Device / Distance / Prior Status
Indoors
Outdoors
# of stairs
Gait Deviations and Limitations:


Balance and Functional Measures: Time Up and Go test score ______sec Tinnetti test score_____/28 Functional reach test score ____inch Berg ____
Balance impairment: Sitting Static: ______dynamic______Standing: Static: ______dynamic______
Specific balance issues: ______

______
Home Bound Status: __patient needs taxing effort to leave home ___unable to walk to elevator or street __Bed bound __medical restrictions __Residual weakness __Requires assistance for all activities __Confusion unable to leave home alone__ severe SOB
Home Assessment: ______
______
Intervention and Plan of Care: __Functional Gait Training__ Transfer Training__ Progressive balance & coordination training___ Progressive Therapeutic Exercise___ ROM Exercise___ Establish and upgrade Home Exercise program__ Falls prevention management

Patient Name: ______Date: _____/______/______
Current Functional Problem / Functional Goals and Outcome
Decreased functional endurance / Goal: Increase functional mobility: Circle choice (walk to car / elevator / mailbox / ______) in ______(wks).
Decreased / Alteration in ROM / Goal: Increase ______joint PROM to improve functional mobility in ______(wks).
Other:
Presence of Pain
/ Goal: Decrease pain to ___ (0-10) via position change (circle choice – rest / meds / joint protection ) during ______(mobility, transfers, gait, other) to improve overall safety and functional performance in ______(wks)
Other:
Decreased Standing / Sitting balance / Goal: Improved upright stability and safety to ambulate ______
(level of assistance) with a ______(device) in (home, community) as seen by a score of _____ on (Tinetti, Berg, TUC) in ______(wks)
Other:
Decreased/impaired Bed Mobility / Goal: Supine to sit with ______assist in ______(wks)
Goal: Sit to supine with ______assist in ______(wks)
Other:
Impaired Transfer Skills / Goal: Improve ______(type) transfers to ______with (assistance) and ______(specific device) in ______(wks).
Impaired Gait / Goal: Ambulate with ______(max to modified independent/ independent assistance) ______feet with ______(device) safely in the home / community in ______(wks)
______(level of assist) on stairs with ____ (device)(handrail) ______no of steps with a decrease in RPE score of < ______by (wks)
Other:
Safety, Impaired, Potential for Injury / Goal: Reduce fall risk as seen by (Tinetti, Berg, TUG) score of ______or greater in ______(wks)
Goal: Patient/caregiver will demonstrate good understanding of safety / compensatory techniques ______% of time in ______(wks)
Other:
Patient Name: ______Date: _____/______/_____
Patient Name: ______Date: _____/______/_____
Current Functional Problem / Functional Goals and Outcome
Decreased Strength / Goal: Increase strength of ____ (RUE/RLE/LUE/LLE) to ______(P to N) in order to transfer from various height surfaces ______(level of assistance) on first attempt in____ (wks)
Goal: Increase ______strength to _____ in order to ______(functional ability – climb stairs, walk safely) in ______(wks)
Other:
Disease Process / Condition management, Knowledge defecits related to patient /caregiver / Goal: Verbalize/demonstrate understanding of home exercise program in _____ (wks)
Goal: Patient will understand limitations related to disease process/condition in______(wks)
Other:
Prosthesis / Goal: ____ (level of assist) on stairs with ______(device/handrail) _____ # of steps with a decrease in RPE score of <_____ in ______(wks)
Goal: ____ (level of assist) on uneven sufaces with ______(device/handrail) _____ # of steps with a decrease in RPE score of <_____ in ______(wks)
Other:


Skilled intervention provided this visit: ______
______
Functional Assessment: ______
______
Prognosis: ___ Poor___ Guarded___ Fair___ Good Frequency and duration of treatment: ______
Impairments, Goals and Plan of Care discussed with LPTA __ MD__ RN__ CM__ other____ Re:: Name ______
Plan of care discussed with patient/Caregiver: Yes No Patient Signature:______

Therapist Name: ______Signature/Title: ______
Physician Name Physician’s Signature:

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