Athletic Therapy Re-Evaluation/Progress Report

Date of Report: [date of report]

Reporting Period: [start date] to [end date]

Visits: [X visits this period; Y total episode visits]

Patient: [name, DOB, MRN]

Clinician: [name, credentials]

Condition: [body region/diagnosis, onset date, mechanism]

Precautions: [current restrictions, weight-bearing status, bracing if applicable]

Report Trigger: [scheduled interval report / change in status / return-to-play assessment / discharge planning]

Subjective

[Patient-reported status since last formal report] (Summarize current symptoms including pain intensity and behavior; functional abilities and limitations; response to prior treatment; adherence to visits and home program; intercurrent events such as new symptoms, imaging, or procedures; and any updated patient goals. Combine into a concise narrative.)

(If no meaningful subjective changes since last session, state that no interval changes were reported and reference daily notes. If the patient did not present for scheduled reassessment, state that subjective update is unavailable and that report was compiled from prior session notes.)

Objective

Measure	Baseline	Current	Change	Notes
[Measure name]	[Baseline value/date]	[Current value/date]	[Direction and magnitude]	[Context, pain response, reliability notes]
[Additional measure]	[Baseline value]	[Current value]	[Change]	[Notes]

(Include ROM, strength, functional performance tests, and PROMs as applicable. Do not re-document unrelated systems or normal findings. If a measure was not tested, document the reason.)

[Pertinent examination findings] (Summarize observation, movement quality, and current functional status relevant to the condition.)

Assessment & Goal Progress

[Clinical interpretation] (Synthesize subjective and objective findings; describe response to treatment; identify current barriers or limiting factors; provide updated prognosis with rationale.)

Goal	Target	Status	Evidence
[Goal description]	[Objective target and timeframe]	[met / progressing / not met / revised / discontinued]	[Supporting objective data]
[Additional goal]	[Target]	[Status]	[Evidence]

(If a goal is revised or discontinued, document the change and rationale.)

[Justification for continued skilled care or discharge readiness] (Provide rationale tied to objective deficits, safety, and functional needs.)

Plan

Recommendation: [continue / modify / discharge]

Frequency/Duration: [visits per week for X weeks]

Focus: [intervention categories and progression strategy]

Restrictions: [current activity clearance, return-to-play stage, modifications]

Home Program: [key updates to exercises and self-management]

Coordination: [communications to referring provider, referrals recommended]

Next Reassessment: [date or visit threshold per policy]

(If discharging, convert this section to a discharge summary including final functional status, home program provided, return-to-sport/work status, and follow-up instructions.)

Clinician Signature: [name, credentials]

Date/Time Signed: [date and time]