Physical Therapy/Occupational Therapy Referral & Rehab Plan

Referral Date: [Date of referral]

Patient Name: [Full name]

DOB: [Date of birth]

MRN: [Medical record number] (Omit if not available)

Referring Clinician: [Name, credentials, practice/department, phone, fax]

Receiving Therapy Clinic: [Clinic name and contact] (Omit if not specified)

Encounter Context: [Post-operative / Non-operative injury / Chronic or degenerative condition / Post-hospital discharge / Work-related injury]

Laterality/Body Region: [Left / Right / Bilateral], [Anatomic region]

Referral Summary

[One-sentence reason for referral stating functional problem and therapeutic intent]

Requested Discipline(s): [PT / OT / PT and OT]

Requested Setting: [Outpatient / Home health / Hand therapy / Sports PT / Work conditioning / No constraint specified] (Omit if not constrained)

• Primary Diagnosis: [Diagnosis name], [ICD-10 code] (ICD-10 code if available)
• Post-operative Status: [Procedure name], [Surgery date], [Surgeon name] (Include only if post-operative)
• Functional Problems: [Pain, ROM loss, weakness, gait dysfunction, ADL limitations as applicable] (Do not infer diagnoses; if uncertain, describe problem and workup status)
• Relevant Comorbidities: [Comorbidities affecting precautions or prognosis with ICD-10 codes] (Omit if none relevant)

Clinical Context

Date of Injury/Onset: [Date or timeframe]

Mechanism: [Traumatic / Overuse / Degenerative / Post-surgical / Other]

Prior Treatments and Response: [Medications, injections, prior therapy, bracing, self-management with response noted]

Operative Details: [Procedure name], [Surgery date], [Surgeon if different from referrer], [Key intraoperative findings impacting rehab]; [Operative note reviewed / Operative note unavailable] (Include only if post-operative)

Functional Baseline: [Prior level of function including work demands, sport level, ADL/IADL capacity]

Current Functional Limitations: [Primary limitations]

Barriers to Recovery: [Pain / Swelling / Fear-avoidance / Cognitive limitations / Transportation / Other] (Include only if relevant)

Precautions and Restrictions

(Critical safety section. List explicit numeric and qualitative limits. Do not infer parameters. If not explicitly specified, document as "Not specified—please confirm.")

• Weight-Bearing Status: [NWB / TTWB / PWB with percentage / WBAT / Not specified—please confirm]; Assistive Device: [None / Cane / Crutches / Walker / Other]; Time-Based Progression: [Progression schedule if ordered / Not specified—please confirm]
• ROM Restrictions: [Joint], [Plane], [Degrees allowed], applies to [PROM / AAROM / AROM / Resisted motion], duration [Timeframe] / [Not specified—please confirm]
• Strengthening/Loading Restrictions: [Prohibited contractions, lifting limits, load restrictions] / [Not specified—please confirm]
• Immobilization/Bracing: [Device type]; Wear Schedule: [Full-time / Night only / Activity only]; Removal: [For hygiene and therapy only / As tolerated]; Hinge Settings: [Angles if applicable]; Duration: [Timeframe] / [Not specified—please confirm]
• Tissue/Wound Considerations: [Incision care, drain status, wound vac, suture removal timing, scar management, lymphedema precautions] / [Not specified—please confirm]
• Special Medical Precautions: [Hardware restrictions, osteoporosis considerations, cardiopulmonary parameters, neuro precautions, anticoagulation status] / [Not specified—please confirm] (Include only clinically meaningful precautions)

PT Order

(Include this section if PT is requested)

Discipline: Physical Therapy

Diagnoses Addressed: [Primary diagnosis and related problems]

Long-Term Goals: [Measurable, function-oriented goals with objective targets and timeframe] (Use clear metrics: ROM degrees, strength symmetry percentage, gait distance, functional task performance)

Frequency: [Number] visits per week

Duration: [Number of weeks or total visits over timeframe]

Start Date/Timing: [Immediate / Start date / Begin after post-op day or week]

OT Order

(Include this section if OT is requested)

Discipline: Occupational Therapy

Diagnoses Addressed: [Primary diagnosis and related problems]

Long-Term Goals: [Client-centered functional goals for ADLs, IADLs, hand function, or work tasks with objective targets and timeframe]

Frequency: [Number] visits per week

Duration: [Number of weeks or total visits over timeframe]

Splinting Authorization: [Yes—evaluation and custom orthosis fabrication as indicated / No / Not applicable]

Start Date/Timing: [Immediate / Start date / Begin after post-op day or week]

Rehabilitation Plan Overview

[Brief strategy summary describing time-based framework with criteria-based progression; global goals across episode including pain control, ROM restoration, strength and endurance, neuromuscular control, functional capacity]

Outcome Measures: [Appropriate measures for condition: NPRS/VAS, PROMIS, LEFS/UEFI/QuickDASH/ODI/NDI, TUG, 6MWT, hop tests, grip strength]

Expected Episode Duration: [Total weeks or months]; Major Decision Points: [Key reassessment timepoints and criteria]

Phase-Based Protocol

(Timelines are approximate; progression is criteria-based and individualized. Adapt number and naming of phases to condition.)

Phase 1: Protection and Motion

Approximate Timeframe: [Week range post-op or from onset]

Entry Criteria: [Post-op status confirmed, medical clearance, pain controlled, safe with prescribed immobilization]

Goals:

• [Pain target at rest and with ADLs]
• [Edema reduction target]
• [ROM target for joint and degrees, PROM/AROM as allowed]
• [Independence with HEP and precaution adherence]

Interventions:

• Pain/Edema Management: [Cryotherapy, elevation, compression, protected positioning]
• Mobility/ROM: [PROM/AAROM/AROM within restrictions; joint mobilization if allowed]
• Neuromuscular Control: [Isometrics or activation drills allowed by precautions]
• Gait/Function: [Gait training per WB status; transfers; bed mobility]
• Cardiopulmonary: [Upright tolerance, UE/LE ergometer as allowed]
• Education: [Precautions, brace wear, wound care, HEP]

Prohibited Activities: [Movements or loads violating tissue/repair constraints] / [Not specified—please confirm]

Progression Criteria: [Pain threshold with ADLs, ROM target achieved, minimal reactive swelling, safe mobility at current WB status, adequate incision healing]

Phase 2: Strength and Endurance Development

Approximate Timeframe: [Week range]

Entry Criteria: [Phase 1 goals met, ROM within target range, edema controlled, clearance for light resistance]

Goals:

• [AROM target relative to contralateral or full]
• [Strength target: MMT grade or percentage of contralateral]
• [Normalized gait pattern at allowed WB level]
• [Functional task tolerance targets]

Interventions:

• Strength/Conditioning: [Closed-chain and open-chain exercises within precautions; load parameters]
• ROM/Mobility: [Progress to end-range as allowed; soft tissue techniques; joint mobilization]
• Neuromuscular Control: [Balance and proprioception training; movement quality drills]
• Gait/Function: [Progress WB per orders; stair training; task-specific ADLs]
• Cardiopulmonary: [Low-to-moderate intensity conditioning]

Prohibited Activities: [High-load or impact activities; restricted planes of motion; resisted motions not yet cleared]

Progression Criteria: [Full or near-full ROM without reactive swelling, strength threshold, functional tolerance to defined tasks, pain threshold with activity]

Phase 3: Advanced Strength and Dynamic Control

Approximate Timeframe: [Week range]

Entry Criteria: [Phase 2 criteria met, no effusion or reactivity, tolerance of progressive loading]

Goals:

• [Strength symmetry target]
• [Dynamic balance and proprioception benchmarks]
• [Functional task performance targets; job or sport-specific drills at controlled intensity]

Interventions:

• Strength: [Progressive resistance, multi-planar loading, eccentric and concentric emphasis]
• Neuromuscular: [Agility, perturbation, change-of-direction training]
• Plyometrics: [Low-to-moderate intensity if appropriate]
• Work/Sport Preparation: [Task simulation, graded exposure, work hardening elements]

Prohibited Activities: [High-impact, contact, or maximal efforts until criteria achieved]

Progression Criteria: [No pain or swelling response to moderate intensity training, strength symmetry threshold, functional test thresholds met]

Phase 4: Return to Function/Sport

Approximate Timeframe: [Week range]

Entry Criteria: [Phase 3 criteria met, physician clearance if required]

Goals:

• [Full, pain-free ROM]
• [Strength symmetry at target threshold for sport or role]
• [Functional performance tests at target thresholds]
• [Safe return to unrestricted ADLs, work, or sport per criteria]

Interventions:

• Performance: [High-level strength and power training; energy systems training; workload progression]
• Sport/Work Integration: [Noncontact drills → Controlled practice → Full practice → Competition or full duty]
• Injury Risk Reduction: [Movement quality optimization, load management education, maintenance HEP]

Prohibited Activities: [None if criteria met; otherwise specify remaining restrictions]

Discharge/Transition Criteria: [All goals met, independent with HEP, outcome measures at targets, clearance obtained]

Return-to-Function Milestones

Functional Milestones:

• [Walking tolerance target without assistive device]
• [Stair negotiation target]
• [Self-care and ADL independence targets]
• [IADL targets: lifting, carrying, household or work tasks]
• [Safety targets: no falls, precaution understanding]

Return-to-Work: (Include if applicable)

• Current Status: [Off work / Modified duty / Full duty]
• Restrictions: [Lifting limit, push/pull limit, positional tolerances, task-specific limits]
• Expected Timing: [Criteria-based timeline]

Return-to-Sport: (Include if applicable)

• Continuum: Return to participation → Return to sport → Return to performance
• Clearance Criteria: [ROM full and pain-free; strength symmetry threshold; functional test thresholds; psychological readiness; no effusion or pain]
• Stepwise Reintroduction: Noncontact drills → Controlled practice → Full practice → Competition; [Workload progression parameters]
• Final Clearance By: [Referring clinician / Surgeon / Designated provider]

Communication and Follow-Up

• Urgent Contact Indications: Suspected infection, DVT/PE symptoms, neurovascular changes, wound dehiscence, new instability, uncontrolled pain, unexpected functional decline
• Routine Updates: [Progress update timing and frequency]
• Upcoming Follow-Ups: [Next clinic visit date]; [Planned imaging or labs if any]
• Protocol Deviations: Contact referrer if protocol conflicts with evaluation findings or patient factors

Signature

Referring Clinician Signature: ____________________________ Date: ____________

Printed Name/Credentials: [Name, credentials]

NPI: [NPI number] (Include if applicable)

Contact Information: [Clinic address, phone, fax]