Physical Therapy Initial Evaluation (Acute Care Inpatient)

Date/Time: [Encounter date and time]

Patient Location: [Unit and level of care]

Referring Provider: [Provider name; reason for referral if stated]

Primary Diagnosis: [Primary diagnosis; key procedure and date if relevant to mobility]

Therapist: [Therapist name and credentials]

Reason for PT Consult

[Functional question being answered and decisions this note should enable] (One to three sentences. Include clinical snapshot relevant to mobility such as level of care, post-op day, new deficits, or respiratory status. If visit limited by patient being off unit, pain, refusal, or medical instability, document the constraint and its impact on findings.)

Chart Review and Safety Prerequisites

Pertinent History: [Selective PMH impacting mobility and safety; baseline assist needs or prior services if known] (Attribute source as [per patient / per chart / per family / per staff]. Include conditions such as prior stroke, dementia, COPD, heart failure, amputations, neuropathy.)

Current Admission: [Reason for hospitalization and key events affecting mobility] (Include only items relevant to mobility and safety. Attribute source.)

Orders and Restrictions:

• [Activity orders: bedrest / up ad lib / activity as tolerated / progressive mobility step] (State as written. If unknown, document as Unverified and note that mobilization was limited pending clarification.)
• [Weight-bearing status per limb] (State explicitly as ordered. If unverified, document and limit activity accordingly.)
• [ROM restrictions and surgical/medical precautions with parameters: spine / sternal / hip / abdominal / neuro] (Do not infer; state as ordered or Unknown.)
• [Hemodynamic parameters if ordered: MAP, HR, BP, SpO2 thresholds] (State explicit ranges or Unspecified.)
• [Oxygen/ventilation settings required for activity] (Document mode and settings exactly.)
• [Fall risk status; isolation precautions and required PPE]

Lines, Tubes, and Devices: [List lines/devices present and mobility implications] (Include telemetry, IV/central lines, arterial line, Foley, drains, chest tubes, wound vac, trach/vent, HFNC/BiPAP, orthoses. Note which must travel with patient and whether RN/RT assistance required.)

Prior Level of Function and Home Environment

Baseline Mobility: [Independent vs assisted; device used; distance tolerance; stair ability; baseline transfers/bed mobility if not independent; recent falls with mechanism; baseline cognition if different from current] (If unknown, state attempts to obtain and plan to verify. Attribute source.)

Home Setup and Supports: [Living situation; caregiver availability and capacity; home type; entry steps; interior stairs and railings; bathroom setup; baseline DME in home] (If unknown, state Unable to assess and plan to verify. Attribute source.)

Subjective

[Patient-reported mobility-related chief concern and symptoms] (Include main complaint such as weakness, dizziness, pain, fear of falling, dyspnea. Document pain location/quality with numeric rating. Include patient goals, discharge preferences, and willingness to participate. Note symptoms during session to correlate with vitals in Objective. Use direct quotes for new/concerning symptoms, goals, or refusals. If patient unable to report, state reason and alternate source.)

Objective Examination

Precautions Confirmed: [Restate key precautions impacting treatment: weight-bearing, ROM limits, hemodynamic/oxygen parameters, lines requiring management, isolation] (State verification status.)

Cognition and Participation: [Arousal/alertness; orientation; command following; safety awareness; impulsivity; insight; delirium behaviors; communication barriers and strategies used] (Note factors affecting fall risk and learning carryover.)

Vital Signs (Document with position/activity context. Include baseline, during activity, and recovery. Correlate symptoms and document reasons for stopping/limiting activity.)

Position/Activity	HR	BP	SpO2	O2 Setting	Symptoms
[Resting (position)]	[HR]	[BP]	[SpO2]	[Mode/flow or RA]	[Symptoms or none]
[During activity (task)]	[HR]	[BP]	[SpO2]	[Mode/flow]	[Symptoms; reason stopped if applicable]
[Recovery (time/position)]	[HR]	[BP]	[SpO2]	[Mode/flow]	[Symptoms or return to baseline]

(Add rows as needed for orthostatic sequence or multiple activity bouts.)

Systems Screen (Include only findings informing mobility decisions.)

• Cardiopulmonary: [Breathlessness at rest/exertion; cough; endurance; work of breathing]
• Integumentary: [Wounds/incisions impacting mobility or precautions]
• Musculoskeletal: [Gross ROM and strength deficits relevant to transfers/gait]
• Neuromuscular: [Sensation; coordination; tone; balance deficits relevant to fall risk]

Functional Mobility (Use standardized assist terminology. Specify assist level, number of helpers, device, and key cues for each task.)

• Bed Mobility: [Rolling; supine to sit with HOB angle] — [Assist level] x[helpers] with [device/rails]; [cues/observations]
• Sitting Balance: [Static/dynamic balance; UE support needed; time tolerated; symptoms]
• Transfers: [Sit to stand; bed to chair; surface height] — [Assist level] x[helpers] with [device]; [technique/observations]
• Standing Balance: [Static/dynamic] — [Balance level; UE support; loss of balance episodes]
• Gait: [Distance] with [device] — [Assist level] x[helpers]; [deviations; rest breaks; fatigue; physiologic response]
• Stairs: [Steps; rails; pattern] — [Assist level] x[helpers]; [tolerance/safety] (Include if relevant to discharge.)
• Wheelchair Mobility: [Propulsion method; distance; assist level] (Include if primary mobility mode.)

(If task not assessed, document Unable to assess with reason.)

Standardized Outcome Measure: [Instrument name; raw score; interpretation] (Options: AM-PAC 6-Clicks Basic Mobility or Daily Activity, FSS-ICU, gait speed, TUG. If not performed, document reason.)

Assessment

Clinical Impression: [Synthesis comparing current function to PLOF; primary limiting factors; overall safety risk and required supervision level]

Key Impairments and Limitations (ICF):

• Impairments: [LE weakness, impaired balance, orthostatic hypotension, pain, decreased endurance]
• Activity Limitations: [Bed mobility, transfers, ambulation, stair negotiation]
• Participation Restrictions: [Cannot manage home stairs, limited caregiver support]

Prognosis and Rehab Potential: [Expected trajectory with barriers and facilitators] (Barriers: medical instability, delirium, caregiver limitations, home environment. Facilitators: strong baseline, motivation, caregiver availability, good carryover.)

Discharge Disposition Recommendations

Recommended Setting: [Home with assistance and home health PT / SNF / IRF / LTACH] (If uncertain, provide conditional recommendations.)

Rationale: [Link to assist level, physiologic tolerance, cognition/safety, home barriers, caregiver availability, standardized score interpretation]

Recommended DME: [Ambulation device; bathroom safety equipment; bracing needs] (Specify new need vs existing equipment.)

Post-Discharge Therapy: [Home health PT / Outpatient PT / Inpatient rehab] (State rationale and primary goals.)

Inpatient Plan of Care

Frequency: [Sessions per week] for [anticipated duration] (May change with medical status or discharge timing.)

Interventions:

• [Bed mobility training with cueing and safety techniques]
• [Transfer training with appropriate device]
• [Gait training: device selection, pacing, monitoring]
• [Stair training if indicated for discharge]
• [Balance and neuromuscular re-education]
• [Therapeutic exercise with cardiopulmonary monitoring]
• [Breathing strategies and activity pacing as indicated]
• [Patient/caregiver education and DME training]

Nursing Mobility Recommendations: [Specific recommendation nursing can execute: assist level, device, frequency, key precautions, monitoring needs]

Goals:

• [Short-term goal]: [Task] at [assist level] with [device], [distance/reps], without [adverse sign/symptom], within [timeframe].
• [Discharge goal]: [Task] at [assist level] with [device], [distance], maintaining [physiologic parameters].
• [Education goal]: [Patient/caregiver] will demonstrate [skill/teach-back] of [precautions/safe mobility/DME use].

Education Provided: [Topics; method; learner(s); response/teach-back; need for reinforcement]

Team Communication: [Communication to RN/MD/Case Management regarding safety or discharge planning]

Session Exceptions

(Include only if applicable. Document refusals, adverse events, or incomplete evaluation with stated reason, education provided, response taken, and who was notified.)

Signature: [Therapist name, credentials] | [Date/Time of authentication]