Physical Therapy Evaluation Example
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If you’re looking for a physical therapy evaluation example to guide your physical therapy (PT) evaluations with new patients or clients, you’re in the right place.
This article includes information on how to complete physical therapy evaluations, along with physical therapy assessment documentation examples and a free downloadable physical therapy evaluation example template.
A patient evaluation is a document all physical therapists complete during the initial PT visit.
Physical therapists perform patient evaluations in order to gather enough information to make an accurate diagnosis, develop a treatment plan, and build accurate and attainable goals for the patient. The examination consists of a complete subjective and objective examination, followed by an assessment, and, then, a treatment plan.
What is a physical therapy evaluation?
The PT evaluation is a formal, thorough document which will be a part of the patient’s official medical record.
All parties involved—including the referring doctor, patient, insurance companies, and attorneys—-are permitted access (with specific permissions/patient consent) to the PT evaluation.
The PT evaluation starts as a complete clinical examination, which consists of the patient history, systems review, and objective data collection. After the examination is completed, physical therapists will complete a clinical assessment.
Another way to record this information is by using a SOAP note template.
Before the evaluation: Patient intake
Prior to the first patient visit, a patient will complete a patient intake. The patient intake is important to allow the clinician to get a first glance at the patient’s case prior to the visit. That said, the patient intake will serve as a guide to the evaluation.
The patient intake typically includes:
- Patient demographics
- Past medical/surgical history
- Medication history
- Imaging
- Chief complaint
- Description of symptoms, aggs, eases
- History of symptoms
- Patient goals
Sections of the PT examination
When performing the PT examination, it is important that physical therapists are very intentional about the patient. The physical therapist should maintain control and direct the communication to ensure the interview stays focused.
Subjective examination
During this part of the evaluation, physical therapists will review all of the patient intake questions with the patient.
Beyond this, physical therapy clinical impression examples that the PT will delve into in more detail include:
- Chief complaint
- Mechanism of injury
- Previous level of function
- Current level of function
- Aggs/eases
- Severity/pain scale
- Nature
- Neurological symptoms
- Review of imaging and physician reports
The free, downloadable physical therapy evaluation example template, which you can print or save to your electronic health record (EHR), includes sections to collect and record this information.
Objective examination
The objective portion of the examination is the quantitative portion of the examination.
Objective data is the information that is directly observed or collected by the physical therapist during the examination via a multitude of tools.
These measurements include:
- Active and passive range of motion
- Manual muscle testing
- Non-physiological joint motion
- Sensory and neurological testing
- Static postural analysis
- Biomechanical assessment
- Palpation examination
- Gait analysis
- Functional movement assessment
- Special clinical tests and measures
Sections of the PT assessment
The assessment portion of the evaluation is focused on analyzing the information gathered during both the subjective and objective portions of the examination.
The goal is to create a succinct assessment of the patient’s PT needs, treatment, plan of care, and diagnosis.
First, evaluate and synthesize the data from the examination, and ascertain if it is within the physical therapy scope of practice.
Then, the next steps in the assessment portion include:
Establish a diagnosis
During the assessment, the physical therapist will determine what specific ICD-10 code(s) to be used to classify the patient.
Design a customized plan of care
Next, physical therapists will design a customized plan of care according to their medical expertise, research, and expected results.
This plan of care is the overall plan that will be used to help reduce the patient symptoms, allow the patient to return to function, and to meet both the patient and the physical therapy goals.
The plan of care should specify the physical therapy interventions that will be used to treat the patient, as well as the treatment frequency and duration of care (i.e., two times per week for six weeks, at which time a formal reevaluation will be performed).
Physical therapy assessment documentation examples that may be included in the plan of care are:
- Treatment of soft tissue
- Manual therapy
- Neurological reeducation
- Home exercise program
- Functional dry needling
- Taping
- Biomechanical education
- Gait training
- Patient education
- Activities of daily living
Determine prognosis
The prognosis is a statement of how well the patient may do with the established plan of care.
The prognosis is based on many factors, including:
- Past history/recurrence
- Chronicity
- Comorbidities and disease processes
- Acuity of the chief complaint
- Access to care
- Motivation/compliance
Patient goals
Physical therapy goals are established to provide a framework for the treatment plan.
The goals ensure all parties are on the same page, and that the appropriate treatments are being performed. Goals will also guide adjustments to the treatment program if they are not being achieved.
The goals must be consistent, aligned with the patient’s goals, and rooted in function—not pain.
There are both short-term goals (for a duration of care between 2-4 weeks) and long-term goals that are established (for a duration of care between 4-8 weeks and beyond).
Typically, physical therapists use the SMART goals model to establish appropriate and consistent goals.
SMART stands for:
- Specific: Who/what/when/where/why for established goals
- Measurable: Able to track success via objective measurements throughout the duration of care
- Attainable: The goals are attainable in the necessary timeframe
- Realistic: Patients will be able to return to function
- Temporal or time-bound: Able to complete within a designated amount of time
Physical therapy evaluation complexity chart
For commercial and federal insurances, a newer requirement has been added that requires physical therapists to define the evaluation complexity using specific CPT codes. Complexity is based on patient history, examination results, duration of symptoms, and more.
These physical therapy evaluation codes help define the intricacy of a specific patient case, as follows:
- Low complexity: 97161
- Moderate complexity: 97162
- High complexity: 97163
Communicating findings and next steps
After finishing the first visit and recording all information using the physical therapy evaluation example template, it is essential for physical therapists to communicate their findings, the initial prognosis based on contributing factors, as well as the current plan of care with their client. Physical therapists should remain conscious of the interaction and attuned to a patient’s non-verbal cues.
Being gentle with the patient regarding their diagnosis, and setting realistic expectations for the patient, can help to establish a healthy working relationship. Emphasize that physical therapy is a collaborative process and empower the patient to have agency in their care.
Once the patient visit is complete, the physical therapist will take the time to include physical therapy assessment documentation examples to complete that portion of the evaluation, ensure the document is cohesive, and then make it an official part of the patient record.
After sharing it with the necessary parties (with patient consent), the treatment process can begin. A formal reevaluation will take place about six weeks into the patient’s treatment, where physical therapists can adjust the plan of care and establish new goals if needed.
Sources
- American Physical Therapy Association. (2020). Physical Therapy Evaluation Reference Table.
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