Physical Therapy Re-evaluation

Physical Therapy Re-evaluation Note

(Do not infer or fabricate information. Include only details explicitly obtained during the encounter. For repeated measures, include baseline and prior values to demonstrate change.)

Patient: [name/identifiers per facility policy]

Date of Service:

Visit #:

Setting: [OP / HH / SNF Part B / IRF / other]

Rendering Clinician: [name, credentials]

Referring Provider: [name, credentials]

Diagnosis/Condition: [primary medical diagnosis and therapy diagnosis with ICD codes if required]

Reason for Re-evaluation

(Required for billing defensibility. Document using either the paragraph or bullet format below—not both.)

[Trigger category: [status change / new clinical findings / lack of expected progress / revised goals needed / post-hospitalization or surgery / pre-discharge determination]; [date/onset of change] — [brief context]. [Anticipated / Unanticipated]. [New safety concerns or updated precautions, if any].]

• [Trigger category and brief justification]
• [Date/onset and context for change]
• [Anticipated / Unanticipated change]
• [New safety concerns or precaution changes, if any]

Subjective

[Chief functional complaint; pain/symptom status with scale and quantification; functional limitations and change from prior level; perceived response to therapy; HEP adherence and barriers; updated patient goals.] (Format as a brief paragraph. If subjective cannot be obtained, document the reason rather than leaving blank.)

Objective

Vitals: [BP, HR, RR, SpO2 as clinically indicated; note conditions if relevant]

Relevant Exam Findings (targeted to the re-evaluation trigger)

• [ROM: joint, side, measurement; baseline → prior → current]
• [Strength: muscle/group, side, grade; baseline → prior → current]
• [Neurologic screen: relevant findings and changes from prior]
• [Special tests or condition-specific measures: test name, result, comparison to prior]
• [Other impairment measures directly linked to trigger]

(If any measure not assessed, document reason: [contraindicated / deferred / not indicated].)

Functional Performance

• [Transfers: task, assistance level, device, cues; comparison to prior]
• [Gait: distance, surface, device, assistance level, deviations; comparison to prior]
• [Stairs/curbs: number, rail use, assistance level, pattern; comparison to prior]
• [Balance: static/dynamic tasks with conditions; comparison to prior]
• [Other relevant functional tasks tied to goals/trigger]

Standardized Outcome Measures

(Include instrument name, administration conditions affecting comparability, and whether change is clinically meaningful. If no standardized measure used, document reason and substitute measurable functional outcomes.)

Measure	Baseline Score	Prior Score	Current Score	Interpretation
[Instrument name and conditions]	[value, date]	[value, date]	[value, date]	[Improved / Stable / Worsened; clinically meaningful Y/N]
[Additional instrument, if applicable]	[value, date]	[value, date]	[value, date]	[Clinical interpretation]

Assessment

[Synthesis of change in status and clinical significance, linking objective findings to impairments, activity limitations, and participation restrictions. Reference the re-evaluation trigger.]

[Progress toward prior goals: [met / partially met / not met] with objective support for each.]

• Prioritized Problem List (safety impact first, then functional impact)
  • [Problem 1]
  • [Problem 2]
  • [Problem 3]

Skilled Need Rationale: [Explanation of why continued PT is necessary vs unskilled care, tied to problems and risk if not addressed.]

Prognosis: [Rehabilitation potential and anticipated timeframe. If progress is slow/variable, identify barriers and mitigation plan.]

Goals & Plan of Care

Goal Status

• [Prior Goal 1] — [Met / Continue / Modify / Discontinue]: [brief objective justification]
• [Prior Goal 2] — [Met / Continue / Modify / Discontinue]: [brief objective justification]
• [Additional goals as applicable]

Updated Goals (Each goal: behavior/function, measurable criterion, conditions, timeframe; link to objective measure.)

• [Short-term Goal 1]
• [Short-term Goal 2]
• [Long-term Goal]

Revised Plan

• Frequency/Duration: [x sessions/week for y weeks]
• Intervention Approach: [planned interventions and progression rationale]
• Precautions/Contraindications: [new or updated]
• Coordination: [MD follow-up, referrals, DME needs]
• HEP: [content, dosing, progression, adherence supports]
• Next Reassessment: [expected timing]

POC Modification Statement: [What changed and why, e.g., "POC modified: frequency increased to 3x/wk for 2 weeks due to post-fall decline; balance training prioritized."]

(If provider certification required: [Certification sent on [date] via [method] / Pending provider signature].)

Signature

[Clinician signature, credentials, date/time] (If assistant contributed, document per supervisory policy.)