PT Forms

INITIAL
UPDATED
PHYSICAL THERAPY CARE PLAN

Diagnosis/ Reason for PT:
Frequency and Duration:
ONSET:
If applicable, portion of Plan of Care assigned to a PTA was discussed, explained to the PTA:
Yes
INTERVENTIONS
No
N/A
Locator #21
Evaluation
Balance training /activities
Teach hip safety precautions
Establish/ upgrade home exercise program
Pulmonary Physical Therapy
Copy given to patient
Ultrasound to _____ at _____ x _____ min
Teach safe/effective use of adaptive/assist

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:
LONG TERM GOALS
SHORT TERM GOALS
Locator #22
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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 lie back down within _____ weeks.
Pt. will be able to butt scoot within _____ weeks.
Pt. will be able to sit up independently _______ within ______ weeks.
Pt. will be able to sit up with/without assistance _______ within ______ weeks.
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.
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.
_____ within ____ weeks.
STAIR/UNEVEN SURFACE
Pt. will be able to climb stair/uneven surface with/without assistance _____ steps #
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.
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.
ROM
Pt. will increase ROM of ________ by ______ degrees
flexion/extension within _____ weeks.
ROM
Pt. will increase ROM of ________ by ______ degrees
flexion/extension within _____ weeks.
SAFETY
SAFETY
Pt. will be able to use _____ independently to _____ feet within ______ weeks.
Pt. will be able to use _____ with/without assistance to _____ feet within ______ weeks.
Pt. will be able to self propel wheel chair _____ feet within _______ weeks.
Pt. will be able to propel wheel chair _____ feet within _______ weeks.
HEP will be established and initiated.
Pt will be able to finalize and demonstrated to follow up HEP.
Locator #22
ADDITIONAL SPECIFIC THERAPY GOALS
Note: Each modality specify location, frequency, duration, and amount.

Patient Expectation
SHORT TERM
Time Frame LONG TERM
DISCHARGE PLANS DISCUSSED WITH:

Patient/Family
Physician
Other (specify)
Care Manager
CARE COORDINATION:
MSW Aide
PTA
REHAB POTENTIAL:
Physician
Other (specify)
Poor
Fair
OT
Good
Equipment needed:
Patient/Caregiver aware and agreeable to POC:
Plan developed by:
Physician signature:
SN
Time Frame
APPROXIMATE NEXT VISIT DATE:

PLAN FOR NEXT VISIT
ST
Excellent
Yes
No (explain):
Date
Therapist Name/Signature/title
Date
Please sign and return promptly, if applicable
Original - Patient Chart
Copy - Patient's Home Chart
PATIENT NAME - Last, First, Middle Initial
ID#
PHYSICAL THERAPY
Cruz & Sanz Health Services, Inc.
EVALUATION
TIME IN
HOMEBOUND REASON:
Needs assistance for all activities
Residual weakness
Requires assistance to ambulate
Confusion, unable to go out of home alone
Unable to safely leave home unassisted
Severe SOB, SOB upon exertion
Medical restrictions
Dependent upon adaptive device(s)
Other (specify)
Evaluation
Ultrasound
Therapeutic Exercise
Electrotherapy
Transfer Training
Prosthetic Training
Muscle Re-education
DATE OF SERVICE
OBJECTIVE DATA TESTS AND SCALES PRINTED ON OTHER PAGE.
PT ORDERS:
RE-EVALUATION
OUT
TYPE OF EVALUATION
Initial
Interim
SOC DATE
Final
(if Initial Evaluation, complete Physical Therapy

Care Plan)
Home Program Instruction

Other:
Gait Training
Chest PT
PERTINENT BACKGROUND INFORMATION

TREATMENT DIAGNOSIS/ PROBLEM
ONSET
MEDICAL PRECAUTIONS:
Fractures
Cardiac
Cancer
Diabetes
Infection
Assistive Device:
Needs:
Respiratory
Immunosuppressed
Osteoporosis
Open wound
Other (specify)
PRIOR/CURRENT LEVEL OF FUNCTION

Prior level of function (ADL/IADL) Specify: (ADL/IADL On Problematic Areas)
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Hypertension
MEDICAL HISTORY
Has:
Current level of function (ADL/IADL) Specify: (ADL/IADL On Problematic Areas)
LIVING SITUATION
Capable
Able
Willing caregiver available
Limited caregiver support (ability/willingness)

No caregiver available
HOME SAFETY BARRIERS:
PERTINENT MEDICAL/SOCIAL HISTORY AND/OR

PREVIOUS THERAPY RECEIVED AND OUTCOMES
Throw rugs
Needs railings
Steps (number/condition)
Other (specify)
Needs grab bars
Clutter
Alert
BEHAVIOR/MENTAL STATUS
Oriented
Conf used
Cooperative
Impaired Judgement
Memory deficits
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:
Edema:
Sensation:
Skin Condition:
Communication-
T.P.R.:
Muscle Tone:
Posture:
Vision:
Hearing:
Endurance:
Orthotic/ Prosthetic Devices:
PART 1
Clinical Record
PATIENT/CLIENT NAME - Last First, Middle Initial
PART 2
Therapist
ID#
PHYSICAL THERAPY EVALUATION
PHYSICAL THERAPY (Cont'd.)
EVALUATION
MUSCLE STRENGTH/FUNCTIONAL ROM EVAL
Shoulder
ACTION
Flex/Extend
Abd./Add.
Int. rot./Ext. rot.
ASSIST
SCORE
TASK
ASSISTIVE DEVICES/COMMENTS
Roll/Turn
Sit/Supine
Scoot/Bridge
Flex/Extend
Forearm
Sup./Pron.
Wrist
Flex/Extend
Fingers
Flex/Extend
Hip
Flex/Extend
Int. rot./Ext. rot.
Ankle
Plant/Dors
Foot
Inver/Ever
Floor
Static Sitting
Dynamic Sitting
Static Standing
Dynamic Standing
Propulsion
W/C SKILLS
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Flex/Extend
Toilet
Auto
Abd./Add.
Knee
Bed/Wheelchair
Elbow
TRANSFERS
Sit/Stand
BALANCE
LOWER EXTREMITIES
UPPER EXTREMITIES
AREA
FUNCTIONAL INDEPENDENCE/BALANCE EVAL
ROM
Right Left
BED MOBILITY
STRENGTH
Right
Left
RE-EVALUATION
Pressure Reliefs
Foot Rests
Locks
OBJECTIVE DATA TESTS AND SCALES

MANUAL MUSCLE TEST (MMT) MUSCLE STRENGTH
FUNCTIONAL RANGE OF MOTION (ROM) SCALE
GRADE
5
4
3
2
1
0
DESCRIPTION
Normal functional strength - against gravity - full resistance.
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.
GRADE
5
4
3
2
1
5
4
3
2
1
0
NORMATIVE DATA FOR JOINT MOTION (ROM)
Elbow
Forearm
Wrist
Fingers
BALANCE SCALE (sitting - standing)

DESCRIPTION
GRADE
106% active functional motion.

Less than 25%.
AREA
Shoulder
DESCRIPTION
Physically able and does task independently.
Verbal 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% - 50% patient/client effort.
Totally dependent-total care/support
1
0
FUNCTIONAL INDEPENDENCE SCALE (bed mobility, transfers, W/C skills)

GRADE
5
4
3
2
DESCRIPTION
Hip
Independent
Verbal 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.
Knee
Ankle
Foot
ACTION/MOVEMENT
o
158 Extend
Flex
o
170
Abd.
o Add.
70
Int. rot.
Ext. rot.
145 o Ext.
Flex
o
85 Pron.
Sup.
o
73 Ext.
Flex
o
90
Flex all
Ext.
o
901-115 Ext.
Flex
o
45 Add.
Abd.
o
45 Ext. rot.
Int. rot.
o
Flex
135 Ext.
o
Plant.
50 Dors.
Inv.
30 o Ever.
55 o
50
o
90
0o
o
70 o
70
o
0
25 o
o
30
45o
10o
o
20
o
20
GAIT
ASSISTANCE:
SBA
Min. assist
Mod.assist
Max. assist
Unable
Stairs (number/condition)
DISTANCE:
PWB
WBAT
TDWB
NWB
WEIGHT BEARING STATUS:
FWB
ASSISTIVE DEVICE(S):
Cane
Quad cane
Crutches
Hemi-walker
Wheeled walker
Walker
Other (specify)
SURFACES:
Independent
Level
Uneven
FOR RE-EVALUATION USE ONLY:

IF A PREVIOUS PLAN OF CARE WAS ESTABLISHED, THEN IT WILL:
CHANGE
NOT CHANGE
QUALITY/DEVIATIONS:
PATIENT INFORMATION
PATIENT'S NAME:
THERAPIST'S
SIGNATURE/TITLE
MED. RECORD #:
DATE
/ /
PHYSICIAN'S
DATE
SIGNATURE
* If no changes made to Initial Plan of care, MD signature no required.
/ /
PHYSICAL THERAPY
WEEKLY SUMMARY REPORT
Bedrest/BRP
Transfer Bed/ Chair
Up as Tolerated
ACTIVITIES PERMITTED: Complete Bedrest
No
Weightbearing
Independent
at
Home
No
Restrictions
Full Weightbearing Partial Weightbearing
Hoyer
Lift
Stair Climbing
Cane
Crutches
Walker
Wheel Chair
Other
Disoriented Agitated
Comatose Depressed Lethargic
MENTALSTATUS: Oriented Forgetful
Other
Subjective Comments:
Specific Safety Issues Addressed:
Ambulates with Assist

Uses W/C, Walker, Cane
Severe Weakness Paralysis Unable to walk
Other
Severe SOB
Bed bound
Up in Chair with max assist
Balance/Gait - Unsteady
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HOMEBOUND STATUS
DUE TO:
INSTRUCTED:
Pt.
C.G
TREATMENT RENDERED (If Pt/CG. instructed. see response below)

Assessment
Therapeutic Exercises
Adaptive Equipment
Transfer Training
Gait Training
EMS, Ultrasound, Massages, Hot/Cold Pack
Energy Conservation
Other
PLAN OF CARE: PROBLEM - ACTION/PROGRESS TOWARD GOALS - PT'S/CG's RESPONSE TO TREATMENT/INSTRUCTION
Interdisciplinary Communication:
Date/Describe:
Next Scheduled Visit Date:
Additions to Plan of Care
Patient Name
Therapist Name/Signature/Title
R.N.
P.T./P.T.A.
O.T./OTA
S.L.P.
Plan for Next Visit:
Date:
M.S.W.
H.H.A.
M.D.
PHYSICAL THERAPY
REVISIT NOTE
TRINITY HEALTH SERVICES, INC.
DATE OF SERVICE:
PT ID PERFORMED VIA NAME, DOB, AND ADDRESS
VITAL SIGNS: Temperature:
Pulse:
/
Blood Pressure: Right

PAIN:
None
Same
Regular
/
Left
Improved
Worse
Lying
OUT
Irregular Respirations:
Standing
Sitting
Regular
Irregular
O2 saturation ____ % (when ordered)
Location(s)
Origin
Intensity 0- 10
Duration
TIME IN
Relief measures
Other
TYPE OF VISIT:
Revisit SOC DATE:
Revisit and Supervisory Visit
Other (specify)
HOMEBOUND REASON:

Residual weakness
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''.)

Balance training/activities
TENS
Ultrasound (B7)
Electrotherapy (B8)
Prosthetic training (B9)
Preprosthetic training
Fabrication of orthotic device (B10)
Muscle re-education (B11)
Modality used
Location
Frequency
Duration
Intensity
Other
Modality used
Location
Frequency
Duration
Intensity
Other
ROM:
STRENGTH:
BALANCE:
MOBILITY/TRANSFER/AMBULATION:
ASSESSMENT/PATIENT'S PROGRESS:
SKILLED INTERVENTION (OUTCOME):

Teach safe/effective use of adaptive/assist
device (specify)
Other:
Cardiopulmonary PT
Pain Management
CPM (specify)
Functional mobility training
Teach bed mobility skills
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Patient/Family education
Therapeutic exercise (B2)
Transfer training (B3)
Gait training (B5)
Management and evaluation of care plan (B12)

Pulmonary Physical Therapy (B6)
Evaluation (B1)
Establish/Upgrade home exercise program
Modality used
Location
Frequency
Duration
Intensity
Other
SAFETY ISSUES
Obstructed pathways
Home environment
Stairs
Unsteady gait
Verbal cues required
Equipment in poor condition
Bathroom
Commode
Others:
TEACHING, TRAINING, RESPONSE TO INSTRUCTIONS:
Reviewed/Revised with patient involvement.

CARE PLAN:
If revised, specify
To CG Family
To Patient
INSTRUCTION ABOUT: Treatment, Equipment
Need for referral (specify)
Other: ______________________
Other: ______________________
TEACHING/TRAINING OF
PLAN FOR NEXT VISIT:

PATIENT/FAMILY RESPONSE TO INSTRUCTIONS:
(specify)
Patient/Family
Physician
Other (specify)
Care Manager
BILLABLE SUPPLIES RECORDED?
N/A
Yes (specify)
CARE COORDINATION:
HHA
MSW
SN
Physician
PT/PTA
Other (specify)
OT
CARE PLAN UPDATED?
SLP
No
Yes (specify, complete Modify Order)
If PT assistant/aide not present, specify date he/she was

/
/
contacted regarding updated care plan:
SIGNATURES/DATES
Patient/Caregiver (if applicable, optional if weekly is used)
Date
PART 1 - Clinical Record

Complete TIME OUT prior to signing below.

Therapist (signature/title)
PART 2 - Therapist
ID#
Date
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
Unable to safely leave home unassisted Severe SOB, SOB upon exertion
Other (specify)____________________________________________________________
TYPE OF EVALUATION
13TH VISIT Supervisory
19TH VISIT 30 day visit
Other visit:
Indicate # ______
SOC Date____/____/_____
TREATMENT DIAGNOSIS(ES) / PROBLEMS IDENTIFIED AT START OF CARE
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________________________________________________________________________________________________________
________________________________________________________________________________________________________
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
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
Community Mobility (gait/wheelchair/scooter): Independent Needed assistance Unable Equipment used: _____
________________________________________________________________________________________________________
LIVING SITUATION
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)__________________________________________________
Alert Oriented Cooperative Confused Memory deficits Impaired judgment Other (specify)__________
________________________________________________________________________________________________________
CCURRENT PAIN
Location(s) ________________________________________________________________
Pain (describe) ______________________________________________________________
Impact on
Function_____________________________________________________________________
1
2 3 4 5 6 7 8 9 10
Previous Pain Level ____________________________________________________________
CURRENT ADL/IADLs
Shoulder
LEFT
RIGHT
LEFT
RIGHT
CURRENT MUSCLE STRENGTH/FUNCTIONAL ROM EVAL

AREA
STRENGTH
ACTION
ROM
(degrees)
Flex/Extend
Abd. /Add.
Int.rot/Ext rot.
Elbow
Forearm
Wrist
Fingers
Flex/Extend
Sup./Pron
Flex/Extend
Flex/Extend
CURRENT FUNCTIONAL INDEPENDENCE/BALANCE EVAL

ASSISTIVE
TASK
LEVEL
DEVICES/
OF
COMMENTS
ASSIST
Bed
Roll/Turn
Mobility
Sit/Supine
Scoot /Bridge
Transfers
Sit/Stand
Bed/Wheelchair
Toilet
Floor
Auto
Flex/Extend
Hip
Abd. /Add.
Balance
Int.rot/Ext rot
Knee
Ankle
Foot
Flex/Extend
Plants. /Dors.
Inver/Ever
PATIENT/CLIENT NAME - Last, First, Middle Initial
Wheel
Chair
Skills
ID#
Static Sitting
Static Standing
Dynamic Sitting
Dynamic Standing
Propulsion
Pressure Reliefs
Foot Rests
Locks
Wheel Chair
Mobility
GRADE
5
4
3
2
1

GRADE
Normal functional strength against gravity - full resistance.
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.
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: __________________
Sensation (describe & include impact on function if appropriate):
BERG or Tinnetti Forms can be attached if appropriate for evaluation
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REHAB POTENTIAL/ DISCHARGE PLANS
Rehab Potential Fair: Pt will develop

functional mobility within the home care
setting
Rehab Potential: Good with PT able to
return to previous level of activity and
improvement in functional status in
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
Current Goals that pertain to current illness
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
Discharge Plan: Pt will be discharged

when Pt is able to function with
assistance of caregiver within current
limitations at home
Other
Progress Toward Goals/ Lack of Progress Toward Goals
Pt. will ______ assist with bed mobility within_____

weeks visits.
Pt. to demonstrate increased strength of ________ (include
specific joint, muscle, and indicate left, right or bilat.) to
_______ within ______ weeks visits
Pt. &/or cg will demonstrate comprehension of home
exercise program within____ weeks visits.
Pt will verbalize pain relief from ___/10 to ____/10 within
____________ weeks visits.
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
Rehab Potential: good for stated

goals
Progress Toward Goals/ Lack of Progress Toward Goals
Other:
Other:
Other:
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):
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Treatment Provided This Visit:
Plan for next visit:
Patient/Caregiver response to Plan of Care:
Care coordination/ interdisciplinary communication ( to address findings and plans to continue) with: Physician SN
Case Manager PTA OT ST MSW Other (specify)______________________________________________
Changes to the POC:
Patient/Client Signature___________________________ Therapist Signature/Title _________________________________

Date ____/____ / _____Time In ________ Time Out_______ Date_____/_____/_______ QI Review Yes Frequency Verified
Yes
ID#
PHYSICAL THERAPY VISIT NOTE

VISIT DATE:
VITAL SIGNS: Pulse:
Blood Pressure: Right
PAIN:
None
Regular
Left
Improved
Same
Location(s)
Constant
Frequency:
Relief Measures
Irregular
/
Respiration:
Lying
Standing
Regular
Sitting
Irregular
Worse
NO HURT
Occasional Intensity 1 - 1 0
Intermittent
HURTS
HURTS HURTS HURTS
HURTS
LITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORSE
N o Pain
Moderate Pain
TYPE OF VISIT:

Residual weakness
HOMEBOUND REASON:
Requires assistance to transfer
Other (specify)
Dependant upon adaptive device(s)
Evaluation
Visit
Visit and supervisory visit
Discharge
Other (specify)
INTERVENTIONS
Gait training
TREATMENT DIAGNOSIS/PROBLEM
Home exercise program upgrade
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Evaluation
Establish rehab. program
Establish home exercise program
Patient/Client/Family education
Therapeutic/Isometric/Isotonic Exercises
Muscle Strengthening
Passive/Active/Resistive exercises
Stretching exercises
Transfer Training
Disease Process and Management
Energy Conservation Techniques
Prosthetic Training
Preprosthetic Training
Pain Management
CPM (Specify)
Functionality Mobility Training
Teach safe/effective use of adaptive/
assist device (specify)
Teach Bed mobility skills
Falls Prevention
Body Mechanics/Posture Training
Pulse Ox
Management and Evaluation of Care Plan
Other:
Muscle/Neuro Re-Education
Breathing/CP Conditioning Exercises
Note: Specify location, amount, frequency and duration with any modality
SAFETY ISSUES
Obstructive pathways
Home environment
Stairs
Unsteady gait
Bathroom
Impaired judgement/safety
Other (specify)
ASSESSMENT/PROGRESS TOWARDS GOALS:
AMBULATION:
STRENGTH:
BALANCE:
ROM:
TRANSFERS/BED MOBILITY:
PATIENT/CAREGIVER RESPONSE:
SUPERVISORY VISIT (Complete if applicable)
PLAN FOR NEXT VISIT:
PT Assistant
Aide
Supervisory Visit:

Patient/Family/Caregiver
Not present
N/A
Unscheduled
Observation of
Care Manager
Physician
Teaching/Training of
Other (specify)
CARE COORDINATION:
MSW
OT
SLP
Other (specify)
Present
Scheduled
None
SN
Physician
PT/PTA
HHA
Case Manager
MEDICATION CHANGE. Since last visit
Patient/Family Feedback on Services/Care (specify)

Care Plan Updated?
Yes
No
Yes (specify)
No
SIGNATURE/DATE:
/
x
/
Date
Therapist (signature/title)
ID#
10
Worst Possible Pain
PHYSICAL THERAPY EVALUATION

OBJECTIVE DATA TESTS AND SCALES PRINTED ON NEXT PAGE
DATE OF SERVICE
/
/
SOC DATE
HOMEBOUND REASON: Needs assistance for all activities
Residual weakness
(If
Initial
Evaluation,
Complete
Physical
Therapy Care Plan)
OTHER DISCIPLINES PROVIDING CARE:
SN
OT
ST
Aide
MSW
Other (specify)
Requires assistance to transfer
PERTINENT BACKGROUND INFORMATION
Chest Pt.
PT ORDERS:
Evaluation
Gait Training
Therapeutic Exercise
Home Program Instruction
Transfer Training
Electrotherapy
Ultrasound
Prosthetic Training
Other:
Muscle Re-education
TREATMENT/DIAGNOSIS/PROBLEM:
MEDICAL HISTORY
Cancer
Immunosuppressed
Arthritis
Other (specify)
REASON FOR EVALUATION (Diagnosis/Problem/History)
.p
n
SA sy
M ste
PL m
E .co
Hypertension
Cardiac
Diabetes
Respiratory
Osteoporosis
Fractures
LIVING SITUATION
Capable
Able
Willing caregiver available
ALF
Limited caregiver support (ability/willingness)
No caregiver available
HOME SAFETY BARRIERS:
None
Clutter
Throw rugs
Bath bench/equipment
Needs grab bar
Needs railings
Steps (number/condition)
Other (specify)
Alert
Oriented ___x1___ x2___ x3
Cooperative
Confused
Memory deficits
Impaired judgement
Other (specify)
PAIN
NO HURT
HURTS
LITTLE BIT
HURTS
LITTLE MORE
HURTS
EVEN MORE
HURTS
WHOLE LOT
HURTS
WORSE
10
LOCATION:
FREQUENCY:
Occasional
AGGRAVATING/RELIEVING FACTORS:
Intermittent
Continuous
PRIOR LEVEL OF FUNCTION
ADLs: Independent
Unable
Level of assistance _________
Equipment Used:
Other:
IN-HOME MOBILITY (gait or wheelchair/scooter):
Independent
Level of assistance ________________ Unable
Equipment Used: No AD Cane/QC Walker/RW WC/Scooter
Other:
TRANSFER MOBILITY:
Independent
Level of assistance ________________
Unable
Other:
COMMUNITY MOBILITY (gait or wheelchair/scooter):
Independent
Level of assistance ____________
Unable
Other:
VITAL SIGNS/CURRENT STATUS
Blood Pressure:
Pulse:
Respirations:
Skin Condition:
Edema:
Vision:
Sensation:
Communication:
Hearing:
Posture:
Activity Tolerance:
Muscle Tone:
Orthotic/Prosthetic devices:
ID#
Continued on Next Page
UPPER EXTREM.
MUSCLE STRENGTH / FUNCTIONAL ROM EVAL
AREA
ROM
STRENGTH
AREA
BED MOBILITY
PHYSICAL THERAPY EVALUATION (Cont'd)

FUNCTIONAL INDEPENDENCE/BALANCE EVAL
ASSIST SCORE ASSISTIVE DEVICES/COMMENTS
TASKS
Roll/Turn
Sit/Supine
Scoot/Bridge
Sit/Stand
Elbow
Bed/Wheelchair
Forearm
Toilet
Wrist
Floor
Fingers
Auto
Hip
Static Sitting
Dynamic Sitting
Static Standing
Knee
Dynamic Standing
Ankle
Propulsion
Foot
Pressure Reliefs
AREA
Foot Rests
ROM
Locks
FUNCTIONAL INDEPENDENCE SCALE (bed mobility, transfers, balance, W/C Skills)
GRADE
DESCRIPTION
DESCRIPTION
GRADE
5
Normal functional strength - against gravity - full resistance
Independent - physically able and independent
6
Supervision and/or verbal cues - 100% patient effort
5
Good strength - against gravity with some resistance
4
4
Contact guard - 100% patient effort
Fair strength - against gravity - no resistance - safety compromise
3
3
Minimum assist (Min A) - 75% patient/client effort
Poor strength - unable to move against gravity
2
2
Moderate assist (Mod A) - 50% patient effort
Trace strength - slight muscle contraction - no motion
1
Maximum assist (Max A) - 25%-50% patient/client effort
1
Zero - no active muscle contraction
Totally dependent - total care/support
0
0
SAFETY ISSUES
FUNCTIONAL RANGE OF MOTION (ROM) SCALE
GRADE
Obstructive pathways
DESCRIPTION
GRADE
DESCRIPTION
Home environment
Bathroom
5
100% active functional motion
2
25% active function motion
Stairs
Impaired judgement/safety
4
Less than 25%
1
Unsteady gait
Other (specify)
3
GAIT
Left
Right
Left
SURFACES:
TRANSFERS
BALANCE
W/C SKILLS
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Independent
Level
SBA
Uneven
WEIGHT BEARING STATUS:

ASSISTIVE DEVICE(S):
Contact guard
Minimum assist
Moderate assist
FWB
WBAT
PWB
Cane
Quad Cane
Other (specify):
TTWB
Crutches
Maximum assist
Unable
DISTANCE/TIME:
Stairs (number/condition)
ASSISTANCE:
SPINE
LOWER EXTREM.
Flex/Extend
Abd/Add.
Int. Rot./Ext. Rot.
Flex/Extend
Sup./Pron.
Flex/Extend
Flex/Extend
Flex/Extend
Abd./Add.
Int. Rot./Ext. Rot.
Flex/Extend
Plant./Dors.
Inver./Ever.
ACTION
STRENGTH
Shoulder
Right
NWB
Hemi Walker
Walker
Wheeled Walker
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)
CARE COORDINATION:
MSW
PTA
PLAN FOR NEXT VISIT
COTA
None
Aide
Physician
SN
PT
OT
ST
Case Manager
Other (specify)
Therapist Printed Name and Title
Therapist (signature)
Date
PHYSICAL THERAPY
CARE PLAN
SOC DATE
Diagnosis:
FREQUENCY AND DURATION:
Patient/Caregiver aware and agreeable to POC and Frequency Duration:
Yes
No (explain)
INTERVENTIONS
Evaluation
Establish rehab. program
Establish home exercise program
Patient/Client/Family education
Therapeutic/Isometric/Isotonic Exercises
Muscle Strengthening
Passive/Active/Resistive exercises
Stretching exercises
Transfer Training
Pain Management
CPM (Specify)
Functionality Mobility Training
Teach safe/effective use of adaptive/
assist device (specify)
Teach Bed mobility skills
Falls Prevention
Body Mechanics/Posture Training
Pulse Ox
Gait training
Home exercise program upgrade
Disease Process and Management
Energy Conservation Techniques
Prosthetic Training
Preprosthetic Training
Management and Evaluation of Care Plan
Other:
Muscle/Neuro Re-Education
Breathing/CP Conditioning Exercises
Monitor Vital Signs: PROVIDE:

U.S. to _______________________________________________ at _______________ warts/cm2 x ___________ minutes.
Pulse
EMS to _____________________________________________________________ x ______________ minutes.
Respirations
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Heat/Cold to _____________________________________________________________ x _______________ minutes.

Therapeutic massage to ___________________________________________________ x ________________ minutes.
Blood Pressure
Joint Mobilization __________________________________________________________________________________
SHORT TERM GOALS
Demonstrate effective pain management within

Improve bed mobility to
weeks
assist within
weeks
Improve transfers to
assist using
within
weeks
Decrease pain level to
within
weeks
Patient to be independent with safety issues in
weeks
Improve wheelchair use to
within
Patient will ambulate with

weeks
feet
L UE to
/5 in
weeks
Increase strength of
L LE to
/5 in
weeks
Improve strength of
to
Increase ROM of
degree extension in
Increase ROM of
Of
/5 within
joint to
in
weeks
weeks
weeks
Ambulation endurance will be

within
weeks
weeks
Fair
L UE to
/5 in
weeks
L LE to
/5 in
weeks
to
/5 within
joint to
weeks
weeks
degree flexion
joint to
degree
Increase ROM of
of
in
weeks
Demonstrate ROM to WNL within
weeks
in
Good
ADDITIONAL INFORMATION:
PTA is following the case
Plan developed by (Name/Signature/Title)
feet
GOALS: PHYSICAL THERAPY

Other
Patient will be discharged to care of self/caregiver with self/caregiver arranged healthcare
Other
Poor
weeks
minutes or
Improve balance to
Other
REHAB POTENTIAL:
DISCHARGE PLAN:
weeks
weeks
device with assist
Patient will ambulate with

within
weeks
Increase ROM of
degree extension in
and
weeks
in
assist using
Improve strength of
degree
weeks
Demonstrate ROM to WNL within

Improve balance to
Other
weeks
assist within
Patient will be able to climb stairs/uneven surfaces

device with
with
assist within
degree flexion
joint to
weeks
within
Improve transfers to
weeks
minutes or
weeks
Patient to be independent with safety issues in

Improve wheelchair use to
within
and
Decrease pain level to
within
Ambulation distance will be

within
weeks
weeks
weeks
Improve bed mobility to
weeks
Patient will be able to climb stairs/uneven surfaces

with
device with
assist within
Return to pre-injury/illness level of function within
Patient will meet maximum rehab potential within

Return to optimal and safe functionality within
device with assist
within
LONG TERM GOALS
Date
ID#
weeks
THERAPY DISCHARGE SUMMARY

PATIENT LAST NAME
FIRST NAME
PATIENT #
PARTIAL - STILL RECEIVING SERVICES OF:

COMPLETE
DISCH DATE
DR
TYPE OF DISCHARGE:
ADM DATE
PT
OT
ST
HHA
SN
ADDRESS
DIAGNOSIS (PRIMARY)
CITY, ST
VISITS RENDERED BY:
RN
HHA
PT
OT
GOALS MET
HOSPITALIZATION
SKILLED NURSING FACILITY
TRANSFER TO ANOTHER AGENCY
REASON FOR DISCHARGE:
ZIP
ST
MSW
MOVED OUT OF AREA

PATIENT EXPIRED
CARE REFUSED
SKILLED CARE NO LONGER NEEDED
OTHER
NH
ACLF
FAMILY CARE
OTHER
IMPROVED
STABLE
UNSTABLE
DECEASED
REGRESSED
DEPENDENT
INDEPENDENT
REQUIRES SUPERVISION/ASSIST
GAIT TRAINING:
N.W.B.
R.U.E.
ACTIVE
R.L.E.
HOYER LIFT
EVEN SURFACES
ASSISTANCE
REQUIRED:
MAXIMUM
DISTANCE
AMBULATED:
20 ft.
INSTRUCTED ON
HOME PROGRAM:
PATIENT
L.U.E.
L.L.E.
RESISTIVE
TRUNK
NECK
CRUTCHES
WALKER
CANE
QUAD CANE
P.W.B.
F.W.B.
STAIRS
UNEVEN SURFACES
MINIMUM
MODERATE
GUARDING
OTHER
40 ft.
60 ft.
80 ft.
100 ft.
SIGNIFICANT OTHER
FAMILY
OTHER
120 ft.
Physical Therapy
NARRATIVE:
ACTIVE ASSISTIVE
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W/C
PASSIVE
SELF CARE
DISPOSITION
CONDITION
DEPENDENCY
EXERCISES
PERFORMED WITH:
TRANSFER
ACTIVITIES:
SUMMATION OF SERVICES RENDERED AND GOALS ACHIEVED
PATIENT HAS ACHIEVED ANTICIPATED GOALS
DEMONSTRATES TRANSFER TECHNIQUE AND USE OF SPECIAL

DEVICES
PATIENT IS SAFELY INDEPENDENT WITHIN DISEASE LIMITATIONS

ABSENCE OF PAIN
DEMONSTRATES ABILITY TO DO SPECIAL TREATMENTS

HEALED INCISION
FREE OF CONTRACTURES
DEMONSTRATES STUMP WRAPPING AND HYGIENE
RANGE OF MOTION OF ALL JOINTS IS WITHIN NORMAL RANGE
DEMONSTRATES TECHNIQUE TO CARE FOR AND PROTECT

FUNCTIONING EXTREMITY
DEMONSTRATES RANGE OF MOTION EXERCISES

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

ADAPTIVE EQUIPMENT
PATIENT HAS REACHED ALL REALISTIC ACHIEVABLE GOALS

PATIENT HAS ATTAINED MAXIMUM BENEFIT FROM THERAPEUTIC
PROGRAM
DEMONSTRATES ENERGY CONSERVATION/WORK SIMPLIFICATION

TECHNIQUES
VERBAL AND SENTENCE FORMULATION AND COMPREHENSION

IMPROVED TO MAXIMUM ATTAINMENT WITHIN DISEASE LIMITATIONS
PATIENT/S.O. RESPONSE AND ADHERENCE TO TEACHING:
DEMONSTRATIONS COMPENSATORY & SAFETY TECHNIQUES
FAIR
GOOD
THERAPY GOALS MET:
YES
NO
IF NO, EXPLAIN
PATIENT/S.O.GOALS MET:
YES
NO
IF NO, EXPLAIN
POOR
COMMENTS:
PATIENTS/So. INSTRUCTED ON IMPORTANCE OF ADHERENCE OF EXERCISE PROGRAM, M.D. FOLLOW-UP AND NOTIFY M.D. IF COMPLICATIONS OCCUR.
DATE
THERAPIST SIGNATURE
White: Medical Records
Yellow: Physician
M.D. NOTIFIED OF DISCHARGE
Visit made
No visit
PHYSICAL THERAPY DISCHARGE SUMMARY

PATIENT
CR#
TO: DR.
ADDRESS
CITY
PARTIAL - continued services
HIC#
1st VISIT
SOC
COMPLETE or
D/C DATE
REASON FOR DISCHARGE:
NUMBER OF VISITS: PT
OT
DIAGNOSES:
SLP
MSS
ADMISSION STATUS
AIDE
DISCHARGE STATUS
Pain due to
ROM
Str/End
Balance
Coordination
Bed Mobility
Transfers
Ambulation
Fine Motor Coord
S/P Awareness
S/P Coord
Receptive Com
Expressive Com
Swallowing
Knowledge level of
Disease Process
HEP
Treatments
Care Management
Safety
Other
Other
, level
.p
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M ste
PL m
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, level
Pain due to
ROM
Strength and Endurance
Balance
Coordination
Bed Mobility
Transfers
Ambulation
Fine Motor Coordination
Sensory/ Perceptual Awareness
Sensory/Perceptual Coordination
Receptive Communication
Expressive Communication
Swallowing
Knowledge level of
Disease Process
HEP
Treatments
Care Management
Safety
Other
Other
ZIP
PROBLEMS IDENTIFIED AFTER START OF CARE:

SELF CARE ACTIVITY ON ADMISSION:
Self Care resumed; or
Assist to be provided by
At d/c:
Transferred
to
or
Instruction,
Observation/Evaluation,
Personal care as ordered,
CARE PROVIDED:
Treatments as ordered,
Other
UNMET NEEDS:
INSTRUCTIONS FOR CONTINUING CARE NEEDS:
Other
Home program,
Equipment management,
ADDITIONAL COMMENTS/ Referrals made:

__
Physician contacted on
Therapist Signature
and discharge is approved.

Date
Physician follow-up,
PHYSICAL THERAPY
DISCHARGE SUMMARY ADDENDUM
PHYSICAL THERAPY GOALS REACHED
MAINTAIN/COMPLY WITH HOME SAFETY PROGRAM
POC (485) GOALS REACHED:

PATIENT DEMONSTRATED CORRECT BODY MECHANICS
PATIENT AND/OR CG COMPREHEND AND DEMONSTRATED
HOME EXERCISE PROGRAM
ABLE TO COMPLY WITH EXERCISES: BOTH PASSIVE AND
ACTIVE EXERCISE REGIMEN
DEMONSTRATED EFFECTIVE FALL PREVENTION
PROGRAM
IMPROVED THE USE OF ASSISTIVE DEVICE: ________________
CARE PLAN SHORT/LONG TERM GOALS REACHED:
PATIENT AMBULATED WITH __________________ (device) FOR

_____________ FT WITH ________ ASSIST
INCREASED STRENGTH OF
RUE
LUE
RLE
LLE
TO ALLOW PATIENT TO PERFORM THE FOLLOWING
ACTIVITIES: _______________________________________.
INCREASED RANGE OF MOTION (ROM) OF
__________________ JOINT TO ________ DEGREE
FLEXION AND ______ DEGREE EXTENSION IN ____
WEEKS TO ALLOW PATIENT TO PERFORM THE
FOLLOWING ACTIVITY: ____________________________.
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
Pt. able to turn side (facing up) to lateral (left/right)
PATIENT EXPERIENCED A DECREASE IN PAIN
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Pt. able to lie back down
DEMONSTRATED EFFECTIVE PAIN MANAGEMENT
BED MOBILITY
ROM
Pt. able to sit up independently _______

Pt. able to self reposition
Pt. increased ROM of ________ by ______ degrees

flexion/extension
IMPROVED BED MOBILITY (INDEPENDENT)

BALANCE
SAFETY
Pt. able to use ________________ independently to ________ feet
Increased tinetti balance score to _____/16
Pt. able to reach steady static/dynamic sitting/standing balance

with/without assistance
Pt. able to self propel wheel chair _________ feet
Pt able to finalize and demonstrated to follow up HEP.
OTHER:
TRANSFER
Pt. able to transfer from _________ to _________ with/without assistance
INDEPENDENT WITH TRANSFER SKILLS

Pt. able to climb stair/uneven surface with/without assistance _____ steps #

_______
ADDITIONAL SPECIFIC THERAPY GOALS REACHED
Patient Expectation
DISCHARGE INSTRUCTIONS DISCUSSED WITH:

Patient/Family
Physician
Other (specify)
Care Manager
CARE WAS COORDINATED: Physician
MSW Aide
PTA
Other (specify)
REHAB STATUS:
Poor
Fair
OT
SN
ST
Good
Excellent
ABLE TO UNDERSTAND MEDICATION REGIME AND CARE RELATED TO DISEASE
DISCHARGED: PATIENT AND/OR CAREGIVER IS/ARE ABLE TO DEMONSTRATE KNOWLEDGE

OF DISEASE MANAGEMENT, S/S COMPLICATIONS.
PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HIS/HER CURRENT LIMITATION AT HOME.
RETURNED TO INDEPENDENT LEVEL OF SELF CARE.
ABLE TO REMAIN SAFELY IN RESIDENCE WITH ASSISTANT OF ________________________
DISCHARGED: MAXIMUM FUNCTIONAL POTENTIAL REACHED
Goals documented by:
LONG TERM
SHORT TERM
ABLE TO REMAIN IN HOME/RESIDENCE/ALF WITH ASSISTANCE OF PRIMARY CAEGIVER/SUPPORT AT HOME

ABLE TO UNDERSTAND MEDICATION REGIMEN, AND CARE RELATED TO HIS/HER DISEASE.
DISCHARGED: MAXIMUM FUNCTIONAL POTENTIAL REACHED.
Date
Therapist Name/Signature/title
ID#
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INITIAL

PHYSICAL THERAPY CARE PLAN

Balance training /activities

Teach hip safety precautions

Establish/ upgrade home exercise program

Pulmonary Physical Therapy

Copy given to patient

Ultrasound to _____ at _____ x _____ min

Teach safe/effective use of adaptive/assist

Copy attached to chart

Electrotherapy to _____ for _____ min

Teach safe stair climbing skills

Teach fall safety

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

LONG TERM GOALS

SHORT TERM GOALS

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

DISCHARGE PLANS DISCUSSED WITH:

APPROXIMATE NEXT VISIT DATE:

PATIENT NAME - Last, First, Middle Initial

Cruz & Sanz Health Services, Inc.

OBJECTIVE DATA TESTS AND SCALES PRINTED ON OTHER PAGE.

(if Initial Evaluation, complete Physical Therapy

Home Program Instruction

PERTINENT BACKGROUND INFORMATION

PRIOR/CURRENT LEVEL OF FUNCTION

Current level of function (ADL/IADL) Specify: (ADL/IADL On Problematic Areas)

Willing caregiver available

Limited caregiver support (ability/willingness)

PERTINENT MEDICAL/SOCIAL HISTORY AND/OR

Needs grab bars

PAIN TYPE (dull, aching, etc):

VITAL SIGNS/CURRENT STATUS

Orthotic/ Prosthetic Devices:

PATIENT/CLIENT NAME - Last First, Middle Initial

PHYSICAL THERAPY EVALUATION

PHYSICAL THERAPY (Cont'd.)

Cruz & Sanz Health Services, Inc.

MUSCLE STRENGTH/FUNCTIONAL ROM EVAL

FUNCTIONAL INDEPENDENCE/BALANCE EVAL

OBJECTIVE DATA TESTS AND SCALES

NORMATIVE DATA FOR JOINT MOTION (ROM)

BALANCE SCALE (sitting - standing)

106% active functional motion.

FUNCTIONAL INDEPENDENCE SCALE (bed mobility, transfers, W/C skills)

FOR RE-EVALUATION USE ONLY:

Cruz & Sanz Health Services, Inc.

Specific Safety Issues Addressed:

Ambulates with Assist

TREATMENT RENDERED (If Pt/CG. instructed. see response below)

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

Plan for Next Visit:

TRINITY HEALTH SERVICES, INC.

VITAL SIGNS: Temperature:

Blood Pressure: Right

O2 saturation ____ % (when ordered)

Ultrasound to ___ at _ x ___ min

Electrotherapy to _ for _ min

TENS to _ for _ min

Heat/Cold to _ for _ min

Therapeutic massage to _ x _ min

Pt. will __ assist with bed mobility within_

Patient/Client Signature_ Therapist Signature/Title _______