PHYSICAL THERAPYN

/ /DATE OF SERVICEOUTTIME INOBJECTIVE DATA TESTS AND SCALES PRINTED ON OTHER PAGE.

TYPE OF EVALUATIONHOMEBOUND REASON: Residual weaknessNeeds assistance for all activitiesFinalInterimInitialConfusion, unable to go out of home aloneRequires assistance to ambulate

/Severe SOB, SOB upon exertionUnable to safely leave home unassisted SOC DATEMedical restrictionsDependent upon adaptive device(s) (If Initial Evaluation, complete Physical TherapyCarePlan)Other (specify)

Chest PTHome Program Instruction Gait TrainingTherapeutic ExercisePT ORDERS: Transfer TrainingEvaluationOther:ElectrotherapyUltrasound Muscle Re-educationProsthetic Training

PERTINENT BACKGROUND INFORMATION

TREATMENT DIAGNOSIS/ PROBLEM

/ /ONSETPRIOR LEVEL OF FUNCTIONMEDICAL HISTORY I

ADLs:FracturesHypertensionUnableNeeded assistanceIndependentCancerCardiac

Equipment used:InfectionDiabetesImmunosuppressedRespiratory

IN-HOME MOBILITY (gait or wheelchair/scooter):Open woundOsteoporosisUnableNeeded assistanceIndependentOther (specify)

Equipment used:

LIVING SITUATIONCOMMUNITY MOBILITY (gait or wheelchair/scooter):

Able Willing caregiver availableCapable UnableNeeded assistanceIndependentLimited caregiver support (ability/willingness) Equipment used:No caregiver available

HOME SAFETY BARRIERS: PERTINENT MEDICAL/SOCIAL HISTORY AND/ORPREVIOUS THERAPY RECEIVED AND OUTCOMESClutter Throw rugs

Needs railingsNeeds grab barsSteps (number/condition)Other (specify)

BEHAVIOR/MENTAL STATUS

Alert Oriented CooperativeConfused Impaired JudgementMemory deficitsOther (specify)

PAIN

INTENSITY: _____________________LOCATION:AGGRAVATING FACTORS/ RELIEVING FACTORS:

VITAL SIGNS/CURRENT STATUS

BP: T.P.R : Edema: Sensation:Skin Condition: Muscle Tone: Posture:Communication Vision: Hearing:Endurance: Orthotic/ Prosthetic Devices:

PART 2 TherapistPART I - Clinical Record -ID#PATIENT/CLIENT NAME - Last First, Middle Initial

PHYSICAL THERAPY EVALUATION

Walker

Walker

Walker

Prior level of function (ADL/IADL) Specify: (ADL/IADL on problematic areas) ______________________________________________________________________ ______________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Current level of function (ADL/IADL) Specify: (ADL/IADL on problematic areas)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EVALUATION RE-EVALUATION

PAIN TYPE (dull, aching,etc):PATTERN (Irradiated):

/

PT ID PERFORMED VIA NAME, DOB, AND ADDRESS

PHYSICAL THERAPY EVALUATION (Cont'd.)

MUSCLE STRENGTH/FUNCTIONAL ROM EVAL FUNCTIONAL INDEPENDENCE/BALANCE EVALASSISTROMSTRENGTH ASSISTIVE DEVICES/COMMENTSAREA TASKACTION

BED

MO

BILI

TYRight Left Right Left SCORERoll/Turn

Sit/Supine

Scoot/Bridge

Sit/Stand

Bed/Wheelchair

Toilet

Floor

Auto

Static Sitting

Dynamic Sitting

Static Standing

Dynamic Standing

Propulsion

Pressure Reliefs

Foot Rests

Locks

Flex/Extend

Abd/Add.

Int. rot./Ext. rot.

Shoulder

UP

PE

R E

XT

RE

MIT

IES

TRAN

SFER

S

Elbow Flex/Extend

Forearm Sup./Pron.

Wrist Flex/Extend

Fingers Flex/Extend

Flex/Extend

Abd./Add.

Int. rot./Ext. rot.-

Hip

LOW

ER

EX

TR

EM

ITIE

S

BAL

ANC

E

Knee Flex/Extend

Ankle Plant/Dors

W/C

SK

ILLS

Foot Inver/Ever

OBJECTIVE DATA TESTS AND SCALESMANUAL MUSCLE TEST (MMT) MUSCLE STRENGTH FUNCTIONAL RANGE OF MOTION (ROM) SCALE

DESCRIPTION GRADEGRADE DESCRIPTIONNormal functional strength - against gravity - full resistance.5

43210

106% active functional motion.75% active functional motion.50% active functional motion.25% active functional motion.Less than 25%,

54321

Good strength - against gravity with some resistance.Fair strength - against gravity - no resistance - safety compromise.Poor strength -- unable to move against gravity.Trace strength - slight muscle contraction - no motion.Zero - no active muscle contraction.

NORMATIVE DATA FOR JOINT MOTION (ROM) FUNCTIONAL INDEPENDENCE SCALE (bad mobility, transfers, W/C skills)ACTION/MOVEMENTAREAGRADE DESCRIPTION

Shoulder 158ºFlex170ºAbd.

70ºIrt. ,rot.

55ºExtend50ºAdd.90ºExt. rot.

ElbowForearmWrist1

Fingers

145º'Flex85ºSup73ºFlex90ºFlex all

0ºExt.70ºPron.70ºExt.0ºExt.-

Hip 90º-115ºFlex45ºAbd.45ºInt. rot.

Ext.30ºAdd,45ºExt. rot.

KneeAnkleFoot

135ºFlex50ºPlant.

I nv. 30º

101ºExt.20ºDors.20ºEver.

Physically able and does task independently.Verbal cue (VC) onlyStand-by assist (SBA-100% patient/client effort.Minimum assist (Min A)-75% patient/client effort.Maximum assist (Max A)-25% 50% patient/client effort.Totally dependent-total care/support

BALANCE SCALE (sitting - standind)25ºGRADE DESCRIPTION

IndependentVerbal cue (VC) only needed.Stand-by assist (SBA)-100% patient/client effort.Minimum assist (Min A)-75% patient/client effort.Maximum assist (Max A)-25% patient/client effort.Totally dependent for support.

GAlT

ASSISTANCE: Independent SBA Mod. assistMin. assist Unable Max. assistSURFACES: Uneven DISTANCE Stairs (number/condition)Level

WEIGHT BEARING STATUS: FWB PWB TDWBWBAT NWBASSISTIVE DEVICE(S): Hemi-walkerCane WalkerCrutch W WalkerQuad Cane

Other (specify)______________________________________________________QUALITY/DEVIATIONS:

EQUIPMENT

PATIENTS'S NAME: MEDICAL RECORD#:_____________________

543210

543210

DATE ____/____/____THERAPIST'S

SIGNATURE/TITTLE DATE ______________ PHYSICIAN'SSIGNATURE :

* if no changes made to initial plan of care, MD signature no required.

Flex/ Int-Ext. Rot.

Flex/Ext/ I-E Rot.Cervical Spine

Lumbar Spine

RE-EVALUATIONEVALUATION

FOR RE-EVALUATION USE ONLYIf a previous POC was establishedthen it will :

CHANGENOT CHANGE

/ /

HAS: NEEDS:

MR#SOC:Resolution:Onset:

Evaluate and assess muscle strength. ROM, ambulation, bed mobility, transfer ability, coordination, balance, endurance, diseaseprocess, pain, home safety, ADL's.Provide:

minutes.watts/cm2 xatUS, tominutesx

x minutesminutesx

Provide and/or instruct in the following:Gait training without assistive devices

( walker/Gait training with

cane) / CG / SBANWBTTWB of R/L L.E.PWB of R/L L.E.

Disease process and managementS/S to report to physicianPulmonary physiotherapyProsthetic/ ortholic trainingInstruct Pt/SO in the following

FWB of R/L LE.As tolerated.Transfer training.Wheelchair training.

Therapeutic/lsometric/Isotonic exercises.

Stretching exerciser.Breathing/CP conditioning exercises.Activities of Daily LivingEnergy conservation

Vital Signs: Pulse Respirations B/P OtherTemperature

Rehabilitation Potential: Good Fair

Frequency:

Physician Signature (if Applicable or Required) Therapist Name, Title, and Signature Date

Passive/Active/Resistive exercises

Home exercise programHome safetySafe stair climbing skillsBed Mobility activities and skillsStatic/dynamic balance training. Muscle re-educations

Fall precautions.Hip Safely precautionsPain managementBody mechanicsPosture training

Stair training

Poor ExcellentDischarge Plan: When goals met Other (specify)

Date.Demonstrates outcomes met by

Pain will decrease to within weeks.Improve bed mobility to assist within weeks.Improve bed mobility to independent within weeks.Improve transfers to assist using within

weeks.Independent with transfer skills within weeks.Improve wheelchair use to withinPatient will ambulate with device with assistwithin weeks.

Patient will be able to climb stair/uneven surfaces withdevice with assist within weeks.

Ambulation endurance will be minutes or

Patient to be independent with safety issues in weeks.

weeks.

feetwithin weeks.Improve strength of to /5within weeks.

Demonstrate proper use of prosthesis/ brace/ splint withinweeks.

Demonstrate effective pain management within weeks.Improve bed mobility to assist within weeks.Pain will be controlled and decreased to within weeks.Improve transfers to assist using within

weeks.Independent with transfer skills within weeks.Improve wheelchair use to withinPatient will ambulate with device with assistwithin weeks.Patient will be able to climb stair/uneven surfaces with

device with assist within weeks.Ambulation endurance will be minutes or

weeks.

feetwithin weeks.

Improve strength of to /5within weeks.Increase ROM of joint to______________in_________weeks.Demonstrate proper use of prosthesis/ brace/ splint within weeks.

Return to pre-injury/ illness level of function within weeks.Patient will meet maximum rehab potential within weeks.Return to optimal and safe functionality within weeks.

Date.

EMS/Tens toHeat toTherapeutic massage toJoint mobilization

INTERVENTIONS

LONG TERM OUTCOME

SHORT TERM OUTCOME

Demonstrated ability to follow home exercise programs by

GOALS: PHYSICAL THERAPY

INTERVENTIONS

PHYSICAL THERAPYCARE PLAN

PATIENT NAME:

/ // /

/ /

/ // /

Muscle strengthening

Increase ROM of joint to________________in _______weeks.

Independent with ambulation with device withinweeks.

Independent with ambulation with device withinweeks.

Patient will demonstrated improve balance (static/ dynamic)to

/ as needed/ as needed

if cream : _______________________/as needed

Time Frame:

Time Frame:

RE-EVALUATIONEVALUATION

SUPERVISORY VISIT (Complete if applicable)

CARE PLAN: Reviewed with Patient /Cg involvement Status reported to MD and POC Approved Care Plan discussed with PTA.

SAFETYISSUESROM:Obstructed pathwaysSTRENGTH:Home environmentBALANCE:Stairs Unsteady gaitAMBULATION:Verbal cues requiredASSESSMENT:Equipment in poor conditionBathroom CommodeOthers:

SUPERVISORY VISIT (Complete if applicable)CARE PLAN: Reviewed/Revised with patient involvement.PT Assistant Aide / Present Not presentIf revised, specify

SUPERVISORY VISIT Scheduled UnscheduledOBSERVATION OFNeed for referral (specify)

TEACHING/TRAINING OFPLAN FOR NEXT VISIT:

PATIENT/FAMILY FEEDBACK ON SERVICES/CARE (specify)DISCHARGE PLANS DISCUSSED WITH: Patient/Family

Care Manager Physician Other (specify)BILLABLE SUPPLIES RECORDED? N/A Yes (specify)

NEXT SCHEDULED SUPERVISORY VISITCARE PLAN UPDATED? No Yes (specify)CARE COORDINATION: PT/PTA OT SLPPhysician

MSW SN HHA Other (specify)

If PT assistant/aide not present, specify date he/she wascontacted regarding updated care plan:

SIGNATURES/DATES

x Complete TIME OUT prior to signing below.

Modality used Modality used Modality usedLocation Location LocationFrequency Frequency FrequencyDuration Duration DurationIntensity Intensity Intensity

VITAL SIGNS: Temperature: Pulse: Regular Irregular Respirations: Regular IrregularLeftBlood Pressure: Right Lying Standing Sitting/ /

Pain: None Same Improved Worse Origin Location(s)Intensity 0-1 0Duration Other Relief measures

HOMEBOUND REASON: TYPE OF VISIT:Needs assistance for all activities Residual weaknessRequires assistance to ambulate Confusion, unable to go out of home alone RevisitUnable to safely leave home unassisted Severe SOB, SOB upon exertion Revisit and Supervisory Visit

Medical restrictionsDependent upon adaptive device(s) Other (specify)

Other (specify)

TREATMENT DIAGNOSIS / PROBLEM AND EXPECTED OUTCOME

PHYSICAL THERAPY INTERVENTIONS/INSTRUCTIONS (Mark all applicable with an ''X''.)Teach safe/effective use of adaptive/assist

device (specify)

Copy given to patientCopy attached to chart

TIME IN OUT

PART 1 Chinical Recoid PART 2 - Therapist

PHYSICAL THERAPYREVISIT NOTE

DATE OF SERVICE: / /

SOC DATE:

PT ID PERFORMED VIA NAME, DOB, AND ADDRESS

/ /

/ / / /

Evaluation (Bl) Balance training/activities Management and evaluation of care plan (B1 2)Establish/ Upgrade home exercise program TENS Pulmonary Physical Therapy (B6)

Ultrasound (B7) Cardiopulmonary PT Teach safe stair climbing skillsElectrotherapy (138) Pain Management Other:

Patient/Family education Prosthetic training (139) CPM (specify)

Therapeutic exercise (132) Preprosthetic training Functional mobility training

Transfer training (133) Fabrication of orthotic device (1310) Teach bed mobility skills

Gait training (135) Muscle re-education (131 1) Teach hip safety precautions

Date DatePatientlCaregiver (if applicable) Therapist (signatureltitte)

ID#PATIENT NAME Last, First, Middle Initial

/ /

Complete TIME OUT prior to signing below_____________________________________________________________________

Therapist (signature/title)