Physical Therapy Initial Evaluation & Plan of Care (Outpatient)

Date of Service: [Date]

Visit Type: Initial Evaluation

Location: [Clinic location/site]

Patient Name, DOB, MRN: [Patient full name] | [DOB] | [MRN]

Referring Provider and Referral Date: [Referring provider name and credentials] | [Referral date / not provided]

Medical Diagnosis/ICD-10: [Medical diagnosis and ICD-10 code(s)]

PT Treatment Diagnosis: [PT treatment diagnosis / movement system classification]

Chief Complaint

[Primary functional problem in one to two lines] (Include brief patient quote only if clinically relevant.)

Subjective

History of Present Illness: [Narrative including onset/date, mechanism if injury-related, symptom behavior with aggravating and easing factors, pain location/intensity/quality, current functional impact, relevant prior care/imaging, and current restrictions or precautions] (Write as a single coherent paragraph.)

Prior and Current Level of Function:

• [Prior level of function: work, ADLs, mobility, recreation, assistive device use]
• [Current functional tolerances and limits: distances, times, specific task limitations]
• [Home environment factors and work/role demands, if applicable]

Relevant Medical History: [Past medical/surgical history impacting prognosis, safety, or plan; prior therapy for this condition and response if known; relevant comorbidities] (List only what is clinically relevant.)

Medications and Allergies: [Current medications or "medication list reviewed in chart"] | [Allergies/adverse reactions relevant to PT] (If unable to obtain, state reason.)

Systems Review: (Document only systems relevant to the presentation; use WNL, impaired, or not tested.)

• Cardiovascular/Pulmonary: [WNL / impaired / not tested] — [Details if impaired]
• Integumentary: [WNL / impaired / not tested] — [Details if impaired]
• Musculoskeletal: [WNL / impaired / not tested] — [Details if impaired]
• Neuromuscular: [WNL / impaired / not tested] — [Details if impaired]
• Cognition/Communication: [WNL / impaired / not tested] — [Details if impaired]

Red Flags: [Screen for progressive neurological deficits, bowel/bladder changes, unexplained weight loss, fever, night pain, DVT signs; document present or absent] (If any present, document clinical action taken.)

Patient Goals: [Patient-stated functional goals, motivation, readiness, preferred activities, and barriers] (Preserve patient voice when helpful.)

Objective Examination

(Quantify all objective data with units, positions, and testing conditions. If an expected measure is omitted, document why.)

Observation: [Posture/alignment, swelling/effusion/atrophy, movement quality, gait deviations, assistive device use and fit, incision/wound status if applicable]

Vitals: BP [value/position] | HR [value] | SpO2 [value] | Pain at rest [score] / with activity [score] (Include only when clinically relevant; if expected but not obtained, document reason.)

Functional Performance:

• Transfers: [Assistance level, technique]
• Gait: [Distance, device, speed/cadence, pattern/deviations]
• Stairs: [Number, pattern, rail use, assistance level]
• Balance: [Static/dynamic measures or standardized test results]
• [Additional functional tasks as applicable: lifting, carrying, reaching]

Region-Specific Measures: (Include only what is relevant to the referral.)

• ROM: [Joint(s), side, degrees, method/position]
• Strength: [MMT grades and/or dynamometry values with units and position]
• Flexibility/Length Tests: [Test name and findings]
• Joint Mobility: [Segment, grade, end-feel, symptom response]
• Palpation: [Tenderness, tissue texture, swelling]
• Special Tests: [Test name and result/interpretation]
• Neurological Screen: [Dermatomes, myotomes, reflexes, neural tension tests as indicated]

Standardized Outcome Measures: [Instrument name] — Score: [value] — Interpretation: [severity anchor/category] (If expected measure not used, document why and note alternative baseline metric.)

Assessment

Clinical Impression: [Synthesis explaining how subjective and objective findings account for the functional problem; key contributing impairments and contextual factors; statement of why skilled PT is required]

Problem List:

• Impairments (body functions/structures): [e.g., decreased ROM, weakness, pain]
• Activity Limitations: [e.g., difficulty with stairs, limited sit-to-stand]
• Participation Restrictions: [e.g., unable to return to work or sport]

Prognosis: [Expected trajectory and anticipated episode duration; factors supporting prognosis; limiting factors; expected discharge status]

Goals

Long-Term Goals (Required): (Each goal must be measurable, time-bound, and tied to a functional limitation.)

• In [timeframe], patient will [task] with [quality/assistance/device] to [participation outcome], measured by [method].
• In [timeframe], patient will [task] with [quality/assistance/device] to [participation outcome], measured by [method].

Short-Term Goals: (Optional; use as milestones toward LTGs.)

• In [timeframe], [impairment/functional change] from [baseline] to [target], measured by [method].

Plan of Care

Required Elements:

• Diagnoses addressed: [Medical and PT treatment diagnoses addressed in this plan]
• Long-term goals: See Goals section above
• Type: Physical Therapy
• Frequency: [Sessions per week; include taper if planned]
• Duration: [Number of weeks and/or total visits]

Planned Interventions: [List interventions with purpose linked to goals/impairments: therapeutic exercise, neuromuscular re-education, gait training, manual therapy, therapeutic activities, modalities, patient education, home exercise program, assistive device training, fall risk interventions as applicable]

Care Coordination: [Plan for POC transmission to referring provider; progress update cadence; referrals or recommendations outside PT scope]

Reassessment Plan: [Interval for reassessment and outcome measure re-testing]

Discharge Planning: [Anticipated discharge criteria; expected discharge disposition]

Signature

Therapist Signature, Credentials, Date: [Signature block]

Plan of Care Established Date: [Date]