Aquatic Therapy Initial Evaluation (PT/OT)

Date of Service: [Date and time]

Patient: [Full name], [MRN], [DOB]

Location: [Clinic name]; [Pool name if multiple]

Evaluating Therapist: [Name], [Credentials], [Discipline: PT/OT], [License number if required]

Referring Provider: [Provider name], [Referral/order date]

Chief Complaint / Reason for Referral

[Patient's primary concern in their own words] [Referral question regarding aquatic therapy candidacy and/or primary rehabilitation goals] (Summarize in 1–2 sentences.)

History

History of Present Condition: [Onset and mechanism if applicable] [Symptom behavior and aggravating/easing factors] [Pain or symptom intensity with scale used] [Prior interventions and responses, including any prior aquatic therapy experience] [Current activity tolerance] [Patient readiness for aquatic participation] (Write as a cohesive narrative.)

Functional Status: [Prior level of function versus current level] [Quantified PT mobility tasks and/or OT ADL/IADL performance] [Falls history] [Assistive device use] [Home/transportation barriers to pool attendance] (Quantify tasks with distances, times, assistance level, and devices when available.)

Relevant Medical/Surgical History: [Cardiac/pulmonary conditions and exercise tolerance] [Neurologic conditions including seizure history] [Skin integrity issues/wounds] [Infectious conditions] [Implanted devices/precautions] (Focus on factors influencing aquatic safety and participation. Document pertinent positives and negatives.)

Medications and Allergies: [Medications affecting exercise tolerance, balance, or heat tolerance] [Allergies relevant to pool environment] [Weight-bearing or ROM precautions from provider] (If unknown, document: Not assessed—[reason].)

Patient-Stated Goals: [2–5 goals in patient's words describing desired outcomes]

Systems Review

(Brief bullets. Specify findings; avoid ambiguous terms like "WNL" without detail. If not assessed, document: Not assessed—[reason]. Any red flags impacting same-day aquatic participation must be reiterated in the Candidacy Disposition.)

• [Cardiopulmonary symptoms with exertion: chest pain, disproportionate dyspnea, syncope]
• [Neurologic red flags: new weakness, unexplained dizziness, changes in consciousness]
• [Signs of infection or systemic illness: fever, diarrhea, open/draining wounds]
• [Cognitive/behavioral concerns affecting safety]

Aquatic Safety Screening and Candidacy

(This section is required for all aquatic evaluations. For any item not assessed, document: Not assessed—[reason].)

Water Readiness: [Swimming ability and water comfort] [Ability to follow safety directions] [Vision/hearing/communication barriers] [Required supervision level: 1:1 in water / close guarding / flotation needs] [Feasibility of entry/exit method and assistance level required]

Infection Control: [Current diarrhea or recent diarrheal illness] [Active skin or respiratory infection] [Immunocompromised status requiring clearance] (Document: [cleared / defer until resolved] for each applicable item.)

Skin Integrity: [Open wounds, surgical incisions, draining wounds, skin infections or rashes] [Waterproof dressing plan if wounds present] [Pre/post skin inspection plan]

Continence: [Urinary or fecal incontinence and management plan] [Ostomy or catheter considerations per facility policy] [Patient acknowledgment of pool safety procedures]

Cardiopulmonary Risk: [Baseline vitals: BP, HR, SpO2] [Heart failure status, unstable angina/arrhythmia history, recent cardiac events] [Oxygen needs or dyspnea at rest] [Airway devices] [Provider clearance status: required / obtained / not needed] [Planned monitoring approach: vitals frequency, RPE targets, symptom stop rules]

Neurologic Risk: [Seizure history with last seizure date and control status] [Balance/ataxia concerns] [Sensation deficits affecting burn risk or foot protection] [Cognitive impairment affecting safe participation]

Thermoregulation: [Heat intolerance or autonomic dysfunction risk] [Planned pool temperature] [Hydration strategy if relevant]

Candidacy Disposition (Required): [Candidacy status: appropriate / appropriate with precautions / deferred] [Specific precautions and modifications required] [If deferred: what must change before proceeding] [Reassessment timeline if applicable] (Write as 2–4 complete sentences.)

Objective Examination - Land-Based

(Include only elements relevant to the presenting problems and aquatic plan. Use standard units and named measures. Specify laterality when applicable.)

• [Observation and posture]
• [Range of motion with goniometric values]
• [Strength with method: MMT grade or dynamometry]
• [Balance and gait measures with scores and assistive devices used]
• [Functional mobility and transfers with assistance level]
• [Pain scales and symptom response to movement]
• [Patient-reported outcome measure(s) with instrument name and baseline score]

Aquatic-Specific Assessment

(Include this section only if the patient entered the water during the evaluation. If candidacy was deferred, omit this entire section.)

Pool Parameters: [Water temperature] [Depth(s) used: waist / xiphoid / chest] [Entry/exit method] [Flotation devices used] [Therapist position and guarding method]

Immersion Response: [Pre-immersion vitals] [Symptoms during immersion and RPE if used] [Post-immersion vitals and recovery] [Adverse events and mitigation if any]

In-Water Performance: [Water walking tolerance and quality] [Balance reactions and perturbation tolerance] [Functional tasks attempted] [Endurance and pacing] [Ability to follow aquatic instructions] (Document assistance level for each task: [independent / supervision / contact guard / min assist / mod assist / max assist] and whether physical or verbal/tactile cueing.)

Assessment / Clinical Impression

[Synthesis of key subjective limitations and objective findings] [Primary impairments and how they drive activity/participation limitations] [Specific rationale for aquatic therapy explaining how buoyancy, viscosity, and hydrostatic pressure address this patient's needs versus land-only intervention] [Skilled need statement explaining why PT/OT services are required rather than unsupervised exercise]

Problem List: (Organize in descending order of severity/impact.)

• [Problem 1]: [Impairment and contributing factors] → [Activity/participation impact] → [Aquatic intervention rationale]
• [Problem 2]: [Impairment] → [Impact] → [Aquatic rationale]
• [Problem 3]: [Additional problems as needed]

Diagnosis

Therapy Diagnosis: [Movement system diagnosis (PT) or occupational performance problem (OT)]

Medical Diagnosis: [ICD-10 code(s) or "per referral"]

Precautions: [Weight-bearing status, ROM limits, surgical protocols, device precautions]

Prognosis

[Expected rate of change] [Anticipated duration of episode of care] [Positive prognostic factors] [Negative prognostic factors] [Anticipated transition from aquatic to land-based program if expected]

Goals

(Measurable, patient-centered, functional goals. Include baseline status, target metric, timeframe, and functional context. Prefer goals testable on land to demonstrate carryover.)

Long-Term Goals:

• [Goal 1: Baseline → Target metric within timeframe for functional task/context]
• [Goal 2]
• [Goal 3]

Short-Term Goals: (Optional)

• [STG 1: Baseline → Target metric within timeframe]
• [STG 2]

Plan of Care

Frequency and Duration: [Visits per week] for [Total weeks]; anticipated total visits: [Count]

Planned Interventions: [Aquatic therapy interventions with intent: strength / endurance / ROM / gait-balance training / neuromuscular re-education / functional task training] [Land-based interventions as indicated] [Patient education topics]

Aquatic Parameters: [Initial water depth and progression plan] [Temperature considerations if relevant] [Equipment to use] [Monitoring plan: vitals frequency, RPE targets, symptom stop rules] [Required supervision level]

Coordination: [POC sent to referring provider: yes/no, date, method] [Additional clearance needed] [Interdisciplinary coordination if required]

Discharge Criteria: [Goal attainment] [Transition to independent aquatic program] [Plateau criteria]

Patient Education

• [Aquatic therapy rationale and expectations] — Patient response: [Verbalized understanding / demonstration / questions]
• [Pool hygiene requirements: pre-shower, wound coverage] — Patient response: [Verbalized understanding]
• [Safety rules and symptom stop rules] — Patient response: [Verbalized understanding]
• [If deferred: requirements before starting] — Patient acknowledgment: [Yes/No]

Treatment Time

(Include only if treatment was performed during evaluation. Aquatic therapy 97113 requires direct 1:1 therapist contact and exercise performed in water.)

97113 Aquatic Therapeutic Exercise: [Timed minutes]; [1:1 in-water / close guarding]; [Brief description of exercises]

Other Codes: [Code, description, timed minutes] (Include additional codes as applicable.)

Total Timed Minutes: [Total] Total Untimed Minutes: [Total]

Signature

Evaluator Signature: [Name, credentials] — [Date/time signed]

POC Transmission: [Date and method if applicable]