Physical Therapy Inpatient Daily Note

Date of Service: [Date]

Patient: [Patient name / MRN]

Provider/Credentials: [Name, credentials]

Location: [Unit / Room]

Precautions: [Weight-bearing status; activity restrictions; isolation; lines/devices affecting mobility] (Include only precautions that impact mobility, safety, or treatment decisions.)

Subjective

[Patient-reported information affecting today's session] (Include stated readiness, pain with scale/location/change, mobility-limiting symptoms such as dizziness/dyspnea/fatigue, function since last visit, and discharge-relevant concerns. If patient unable to report, document reason. Use direct quotes only if they clarify safety or adherence decisions. If not obtained, state "not reported" with reason.)

Objective

Vitals/Response: [Baseline and exertional response as clinically indicated] (For stable patients, a brief tolerance statement is sufficient. For higher-risk patients, include pre/during/post parameters. Document any adverse events or near-events.)

Mobility Performance: (Include only domains addressed today. If a key domain was deferred for safety, note the reason briefly.)

• [Task/Domain]:
  • Assist Level: [Independent / Modified Independent / Supervision / Standby Assist / Contact Guard / Min Assist / Mod Assist / Max Assist / Dependent]
  • Device: [Device/support used]
  • Dose: [Distance / time / repetitions]
  • Safety: [Guarding strategy, cueing type/frequency, environmental needs]
(Repeat for each task performed. Keep entries concise.)

Cognition/Safety: [Orientation, command following, impulsivity, or participation barriers] (Include only when relevant to mobility safety or discharge planning.)

Assessment

[Clinical synthesis: response to today's treatment, progress vs. prior session, primary limiting factors, current fall risk and supervision needs, statement supporting continued skilled PT, and implications for discharge destination/timing/support] (Write 3–5 sentences. Reference objective data from today's performance.)

Plan

Next Session:

• [Focus area for upcoming treatment]
(Include 2-3 brief focus areas as relevant.)

Discharge Recommendations:

• Destination: [Recommended discharge destination with objective justification from today's performance]
• Assistance at Discharge: [Required supervision/assist level for mobility]
• DME: [Recommended devices/equipment]
• Barriers/Next Steps: [Pending caregiver training, medical stability, equipment procurement] (If unchanged from prior, state "unchanged" with brief supporting data.)

Coordination: [Key communications with nursing/case management/medical team regarding mobility status, assistance recommendations, or safety concerns] (Keep brief.)

Treatment Time: [Total minutes; timed-code minutes; start-stop times as required] (Document per facility/payer requirements.)

Signature/Authentication: [Provider signature, credentials, date/time per facility policy]