Aquatic Therapy Re-evaluation/Progress Report (PT/OT)

Patient Name: [Patient name]

DOB: [Date of birth]

Payer: [Payer/Insurance]

Referring Provider: [Referring provider name and credentials]

Diagnoses: [Primary and secondary diagnoses with ICD codes]

Discipline: [PT / OT]

Report Type: [Progress Report / Re-evaluation / Combined]

Reporting Period: [Start date] – [End date]

Visits: [Number of completed visits this period] (Note attendance issues only if relevant to progress interpretation.)

Reason for Report

[Executive summary] (Provide 3–5 sentences that: 1) state why this report is being generated now, 2) highlight 1–3 key functional changes, 3) state whether skilled aquatic therapy remains medically necessary with one-sentence rationale, and 4) outline the plan going forward [continue / modify / transition / discharge].)

Subjective

[Interval history since last report] (Summarize patient-reported changes in function relevant to goals: transfers, ambulation, stairs, ADLs/IADLs, work or role tasks. Include symptom status such as pain, fatigue, stiffness. Document perceived response to aquatic therapy.)

• [Safety-relevant interval events] (Include new diagnoses, hospitalizations, falls, medication changes, or new precautions. Only include if present.)
• [Home program adherence and barriers] (Only include if relevant to progress interpretation.)
• [Patient priorities and occupational roles] (OT reports only.)

Objective

Aquatic Parameters

• Pool/Water Depth: [Setting and depth used]
• Entry/Exit: [Method] with [assistance/guarding level]
• Therapist Position: [in-water / poolside] with [assistance level for in-water activities]
• Flotation/Support Devices: [Devices used]
• Precautions Screening: [Skin integrity, continence, cardiopulmonary tolerance status]
• Vitals: [Pre/post vitals] (Only include if clinically indicated.)

Standardized Measures (If a measure was not repeated, state why and when it will be reassessed.)

Measure	Baseline	Prior Report	Current	Interpretation
[Measure name]	[Score/date]	[Score/date]	[Score/date]	[Interpretation/MCID]
[Measure name]	[Score/date]	[Score/date]	[Score/date]	[Interpretation/MCID]

Functional Performance (Report reproducible metrics and assistance levels; note aquatic-to-land carryover when observed.)

• Transfers: [Type, assistance level, device]
• Sit-to-Stand: [Reps/time, surface height, assistance]
• Gait: [Device, distance, assistance level, surfaces]
• Stairs: [Number of steps, pattern, rails, assistance]
• Balance: [Static/dynamic tasks, assistance level]
• ADLs/Task Performance: [Relevant functional tasks with metrics] (Include as applicable.)

Assessment

Goal Status

Goal ID	Goal Statement	Status	Supporting Evidence
[LTG 1]	[Measurable goal statement with target date]	[Met / Partially Met / Not Met / Discontinued / New]	[Objective data supporting status]
[STG 1a]	[Measurable goal statement with target date]	[Met / Partially Met / Not Met / Discontinued / New]	[Objective data supporting status]

[For goals not met: clinical reason and planned modification] (Only include if applicable.)

Medical Necessity

• Skilled Care Justification: [Why skilled PT/OT is required—clinical judgment, progression decisions, safety management, complex cueing]
• Aquatic Therapy Justification: [Unique properties required—buoyancy, viscosity, hydrostatic pressure, thermodynamics—and why land-based alone is insufficient]
• Episode Type: [Rehabilitative / Maintenance] with [objective support]
• Prognosis: [Concise statement based on objective change, participation, and medical complexity]

[Re-evaluation trigger and plan elements revised] (Only include for Re-evaluation or Combined reports.)

Plan

Goals (Maintain stable goal IDs across the episode.)

• [LTG 1]: [Goal statement] by [Target date]
• [STG 1a]: [Goal statement] by [Target date]

Treatment Plan

• Frequency/Duration: [x sessions/week] for [x weeks]; [anticipated visits or next progress report date]
• Intervention Focus: [Aquatic and land-based components; progression priorities]
• Transition Plan: [Progression toward land-based training] (Only include if applicable.)

Discharge Criteria: [Measurable indicators that will signal readiness for discharge]

Coordination: [Communication with referring provider/payer, pending orders, recertification needs] (Only include if applicable.)

Clinician Signature: [Name]

Credentials: [Credentials and license number]

Date: [Date of signature]