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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
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.)

Cruz & Sanz Health Services, Inc.

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.


75% active functional motion.
50% active functional motion.
25% 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.

/ /

Cruz & Sanz Health Services, Inc.

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:

Needs assistance for all activities


Residual weakness
Requires assistance to ambulate
Confusion, unable to go out of home alone
Severe SOB, SOB upon exertion
Unable to safely leave home unassisted
Dependent upon adaptive device(s)
Medical restrictions
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 stair climbing skills


Teach safe/effective use of adaptive/assist
device (specify)
Other:

Cardiopulmonary PT
Pain Management
CPM (specify)
Functional mobility training
Teach bed mobility skills
Teach hip safety precautions

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Copy given to patient


Copy attached to chart
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)
DISCHARGE PLANS DISCUSSED WITH:
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


PATIENT NAME - Last, First, Middle Initial

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
Requires assistance to ambulate
Confusion, unable to go out of home alone
Unable to safely leave home unassisted Severe SOB, SOB upon exertion
Dependent upon adaptive device(s)
Medical restrictions
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
assistance needed:_________________________________________________________________________________________
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
assistance needed:_________________________________________________________________________________________
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)__________________________________________________
BEHAVIOR/MENTAL STATUS
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

MANUAL MUSCLE TEST (MMT) MUSCLE STRENGTH


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:

PATIENT/CLIENT NAME - Last, First, Middle Initial

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

PATIENT/CLIENT NAME - Last, First, Middle Initial

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:

Needs assistance for all activities


Residual weakness
HOMEBOUND REASON:
Requires assistance to ambulate
Confusion, unable to go out of home alone
Requires assistance to transfer
Severe SOB, SOB upon exertion
Medical restrictions
Unable to safely leave home unassisted
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
Copy given to patient
Copy attached to chart
Patient/Client/Family education
Therapeutic/Isometric/Isotonic Exercises
Muscle Strengthening
Passive/Active/Resistive exercises
Stretching exercises
Transfer Training

Pulmonary Physical Therapy

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 safe stair climbing skills
Teach Bed mobility skills
Teach hip safety precautions
Falls Prevention
Body Mechanics/Posture Training
Pulse Ox

Management and Evaluation of Care Plan

Other:

Muscle/Neuro Re-Education

Breathing/CP Conditioning Exercises

Balance training/activities

Note: Specify location, amount, frequency and duration with any modality

SAFETY ISSUES
Obstructive pathways
Home environment
Stairs
Unsteady gait
Verbal cues required
Equipment in poor condition
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:

DISCHARGE PLANS DISCUSSED WITH:


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
PATIENT NAME - Last, First, Middle Initial

/
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
Requires assistance to ambulate
Confusion, unable to go out of home alone
Therapy Care Plan)
Unable to safely leave home unassisted
Severe SOB, SOB upon exertion
OTHER DISCIPLINES PROVIDING CARE:
Dependent upon adaptive device(s)
Medical restrictions
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)

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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)
BEHAVIOR/MENTAL STATUS

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:

PATIENT NAME - Last, First, Middle Initial

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
Equipment Used: No AD Cane/QC Walker/RW WC/Scooter
Other:
COMMUNITY MOBILITY (gait or wheelchair/scooter):
Independent
Level of assistance ____________
Unable
Equipment Used: No AD Cane/QC Walker/RW WC/Scooter
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
MANUAL MUSCLE TEST (MMT) MUSCLE STRENGTH
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
Equipment in poor condition
DESCRIPTION
GRADE
DESCRIPTION
Home environment
Bathroom
5
100% active functional motion
2
25% active function motion
Stairs
Impaired judgement/safety
75% active functional motion
4
Less than 25%
1
Unsteady gait
Other (specify)
50% active functional motion
3
Verbal cues required
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
Copy given to patient
Copy attached to chart
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 safe stair climbing skills
Teach Bed mobility skills
Teach hip safety precautions
Falls Prevention
Body Mechanics/Posture Training
Pulse Ox

Gait training
Home exercise program upgrade
Pulmonary Physical Therapy
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

Balance training/activities

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

Increase strength of

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)
PATIENT NAME - Last, First, Middle Initial

feet

Increase strength of

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

Increase strength of

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

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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


STAIR/UNEVEN SURFACE

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

PATIENT NAME - Last, First, Middle Initial

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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