Home Health Physical Therapy Start-of-Care Evaluation

Date/Time: [Visit date; start time – end time]

Patient: [Name; DOB/MRN per agency policy]

Clinician: [Name, credentials, license number/state]

Referring/Certifying Practitioner: [Name, credentials]

Primary Diagnosis/Reason for Referral: [Primary diagnosis and referral reason]

Secondary Diagnoses: [Relevant comorbid conditions] (List conditions affecting mobility, endurance, or safety. State "None documented" if none reported.)

Payer: [Medicare / Medicare Advantage / Other payer and plan name]

Reason for Visit

[Brief narrative of why PT is present, including precipitating event/referral reason, patient's primary concern in their own words, and immediate safety concerns] (2–4 sentences. If patient cannot provide information, identify the alternate source used.)

Homebound Status

(Document patient-specific clinical facts demonstrating that leaving home requires considerable and taxing effort. Do not use generic phrases without supporting clinical observations.)

• Mobility limitations and assistance: [Functional mobility deficits; assistive device requirements; hands-on assistance needed; endurance limits]
• Entry/egress barriers: [Number/type of steps; railings; thresholds; lighting; distance to vehicle/transit; terrain]
• Symptoms limiting community egress: [Cardiopulmonary symptoms; balance deficits; pain; dizziness; neurologic issues; fall risk]
• Cognitive/behavioral factors: [Attention; judgment; safety awareness; anxiety; need for supervision] (Include only if applicable.)
• Absences from home: [Medical appointments, dialysis, or brief outings] (Clarify these do not indicate ability to obtain care outside the home. State "None reported" if none.)
• Summary statement: [Concise justification linking above factors to taxing effort required to leave home]

Relevant History

• Medical/surgical history: [Conditions affecting mobility, endurance, or safety] (Source: [patient / caregiver / record])
• Recent hospitalizations/facility stays: [Facility; dates; reason] (State "None in past 60 days" if none.)
• Precautions/contraindications: [Weight-bearing status; ROM restrictions; cardiac precautions; fall precautions] (State "None identified" if none.)
• Prior level of function: [Ambulation; device use; stair ability; ADL independence; prior falls; community participation]
• Therapy-relevant medications: [Medications influencing vitals, cognition, balance, or exercise tolerance]
• Information gaps: [What is missing; why unavailable; plan to obtain] (Omit if no gaps.)

Social & Caregiver Situation

• Living situation: [Alone / with others; relationship; home type; primary living level]
• Caregivers: [Relationship; availability/schedule; willingness and ability to assist] (State "No caregiver available" if applicable.)
• Communication considerations: [Language; hearing/vision; cognition; health literacy] (Include only if affecting plan.)
• Support adequacy: [Whether current supports are sufficient for safe plan implementation; identify gaps]

Subjective

• Pain: [Location; intensity on 0-10 scale; behavior; aggravating/easing factors] (State "Denies pain" if none reported.)
• Symptoms: [Dizziness; dyspnea; fatigue; neurologic concerns; onset/pattern] (State "No additional symptoms reported" if none.)
• Falls in past 12 months: [Number; injuries; near-falls; circumstances; fear of falling] (State "Denies falls or near-falls" if none.)
• Patient-stated goals: [Goals in patient voice; meaningful activities patient wants to resume]
• Reported functional limitations: [Specific home tasks affected and context]

(Source: [patient / caregiver / both]. Clearly distinguish reported information from objective findings.)

Objective

Vital Signs & Activity Response

• Resting vitals: [BP; HR; RR; SpO2; position]
• Orthostatic assessment: [Positions; timing; BP/HR changes; symptoms] (Include if clinically indicated; omit if not performed.)
• Exertional response: [Task performed; HR/BP/SpO2/RPE; symptoms; rest breaks required]
• Clinical actions taken: [Positioning; rest; breathing strategies; provider notification] (Omit if none required.)

Systems Review

(Document targeted observations relevant to mobility and safety.)

• Cognition/behavior: [Orientation; attention; judgment; safety awareness; learning ability]
• Vision/hearing/communication: [Deficits and compensations relevant to mobility and instruction]
• Integumentary: [Skin integrity; edema; wounds/pressure risk relevant to mobility] (State "Intact, no concerns" if unremarkable.)
• Cardiopulmonary: [Breathing pattern; endurance observations; supplemental O2 use]
• Neuromuscular: [Tone; coordination; sensation; motor control]
• Musculoskeletal: [ROM limitations; strength deficits; posture; joint restrictions]

Home Safety & Environmental Assessment

(Required section. Base on direct observation in patient's home.)

• Entry/egress: [Steps; railings; thresholds; lighting; walkway condition]
• Flooring and pathways: [Rugs; cords; clutter; pathway width; pets; lighting]
• Bathroom: [Toilet height; grab bars present/needed; tub/shower access; non-slip surfaces]
• Bedroom: [Bed height/stability; path to bathroom; night lighting]
• Kitchen and common areas: [Mobility space; reaching requirements; fall hazards]
• Interior stairs: [Number; railings; lighting; device management] (State "Not applicable - single level" if none.)
• Immediate risk mitigation performed: [Actions taken during visit and patient/caregiver response] (State "None indicated" if environment safe.)
• Recommendations requiring follow-up: [Home modifications; DME; OT referral] (Omit if none.)
• Areas not assessed: [Area; reason; plan to complete] (Omit if full assessment completed.)

Equipment & Assistive Devices

• Current devices: [Type; fit; condition; patient competency and safety with use]
• Other equipment present: [Oxygen; hospital bed; grab bars; commode; shower chair] (State "None" if no additional equipment.)
• Recommendations: [New equipment; adjustments; repair; training needed; justification] (Omit if none.)

Functional Mobility

(Document assistance level, device used, safety observations, and skilled techniques applied. Include distances, times, and rest breaks.)

• Bed mobility: [Rolling; supine-to-sit; assistance level; strategies; safety observations]
• Transfers: [Sit-to-stand; bed; chair; toilet; shower/tub; assistance level; device; technique]
• Gait: [Distance; surfaces; turns; obstacles; device; assistance level; gait deviations; rest breaks]
• Stairs/entry steps: [Number; rail use; pattern; device management; assistance level] (State "Deferred - reason" if not assessed.)
• Wheelchair mobility: [Propulsion; distance; maneuvering; transfers] (Include only if applicable.)
• Balance: [Static and dynamic balance during functional tasks; protective reactions; postural control]

Standardized Outcome Measures

(Perform 1–3 measures feasible in the home setting.)

• [Test name; conditions (device, assistance); score/time; interpretation and fall risk category if applicable]
• [Additional measure if performed]

(If unable to perform standardized measures, state reason and plan to assess at future visit.)

Assessment

[Clinical summary synthesizing key impairments, activity limitations, home safety barriers, and overall risk profile including fall risk and rehospitalization indicators] (3–6 sentences.)

• Prioritized problem list: [Ordered list linking impairments to functional limitations and home barriers]
• Skilled need rationale: [Why skilled PT is required; complexity; safety risks; clinical judgment needed; why goals cannot be met by unskilled caregiver alone]
• Prognosis: [Good / Fair / Guarded] for stated goals. [Expected trajectory and limiting factors]

Goals

(Goals must be specific, measurable, tied to identified problems, and include safety criteria.)

Goal	Baseline	Target	Timeframe	Conditions
[Functional transfer goal]	[Current performance]	[Objective target]	[Timeframe]	[Device; assistance; location; safety criteria]
[Gait/ambulation goal]	[Current performance]	[Objective target]	[Timeframe]	[Conditions]
[Stair/entry goal]	[Current performance]	[Objective target]	[Timeframe]	[Conditions]
[Bathroom safety goal]	[Current performance]	[Objective target]	[Timeframe]	[Conditions]
[Participation goal]	[Current performance]	[Objective target]	[Timeframe]	[Conditions]

(Add or remove rows based on patient-specific goals.)

Plan of Care

Frequency/Duration: [Visit frequency] for [episode duration]

Interventions:

• [Therapeutic exercise: targeted areas; dosage parameters]
• [Balance and neuromuscular training: focus and progression]
• [Gait training: device optimization; cueing; energy conservation]
• [Stair training: technique; rail use; device management]
• [Transfer training: sequencing; surface variations]
• [Patient/caregiver education: safety; pacing; symptom monitoring; fall prevention]

Home Exercise Program: [Issued today / to be issued next visit; key exercises; frequency; precautions; written materials provided]

Recommendations: [Home modifications; DME with justification; referrals (OT/RN/MSW/provider) with purpose] (Omit if none.)

Coordination: [Who will be notified; regarding what; method; urgent findings] (Omit if none required.)

Discharge Plan: [Anticipated disposition; discharge criteria aligned to goals; caregiver training needs]

Patient/Caregiver Education & Response

• Education provided: [Topics; learners (patient/specific caregiver); methods/materials used]
• Teach-back/return demonstration: [Accuracy; cues required; retained errors]
• Barriers encountered: [Pain; cognition; anxiety; sensory deficits; accommodations used] (Omit if none.)
• Safety warnings: [Specific risks discussed and instructions given]
• Response: [Understanding demonstrated; agreement with plan; concerns expressed]

Signature

Clinician Signature: [Electronic signature]

Credentials/Title: [Credentials]

Date/Time Signed: [Date and time]