Physical Therapy Referral Letter & Rehabilitation Plan

Physical Therapy Referral Letter & Rehabilitation Plan

Date: [Date]

Patient Name: [Patient name]

DOB: [Date of birth]

MRN: [Medical record number]

Referring Clinician: [Name, credentials, NPI, contact information]

Receiving Therapy Clinic: [Clinic name and contact] (Omit if unknown.)

Laterality/Body Region: [Side and anatomical region]

Primary Diagnosis: [Diagnosis with ICD-10 code]

Referral Purpose & Precautions

[Reason for referral, clinical priorities, and key objectives] (Write 2–4 sentences stating indication for supervised PT, primary goals such as pain control, ROM restoration, strengthening, or return to activity. Note urgency if applicable.)

Precautions (If any item is unknown, insert: "UNKNOWN—CONFIRM PRIOR TO ADVANCING.")

• Weight-Bearing Status: [Status and timeline for progression]
• ROM Restrictions: [Specific directional limits with duration]
• Protected Motions/Contraindications: [Movements or loads to avoid]
• Brace/Immobilizer: [Type, settings, wear schedule]

Red Flags Requiring Contact: [Case-specific symptoms warranting prompt communication] (Include thromboembolic signs, wound concerns, infection signs, escalating pain out of proportion, new neurologic deficit, mechanical instability, or other condition-specific red flags as applicable.)

Clinical Summary

Procedure/Injury Details: [Post-op: procedure name, date, key operative findings impacting rehab. Non-surgical: mechanism, onset date, relevant imaging findings.]

Relevant History: [Prior injuries to same region, comorbidities affecting healing or loading tolerance, baseline mobility, anticoagulation status] (Omit if not materially impacting rehab.)

Current Status: [Pain severity and location, swelling/effusion, ROM in degrees, strength deficits, gait/mobility with device and distance tolerance, functional limitations] (Use numbers and measurements. For items not assessed, state "not assessed.")

Therapy Order & Goals

Therapy Type: Physical Therapy

Frequency: [Visits per week]

Duration: [Weeks or number of visits]

Home Exercise Program: [Expectations and frequency]

Patient Goals: [Patient-stated goals] (If not obtained, state: "PT to elicit at initial evaluation.")

Long-Term Goals: (Include 2–3 function-focused, measurable goals with metrics, conditions, and timeframe.)

• [Goal with metric and timeframe]
• [Goal with metric and timeframe]
• [Goal with metric and timeframe]

Short-Term Goals: (Include 1–2 near-term milestones.)

• [Short-term goal with metric and timeframe]
• [Short-term goal with metric and timeframe]

Rehabilitation Plan

(Adjust number of phases to condition complexity.)

Phase 1 - Protection/Early Motion [Timeframe]:

• Focus: [Primary objectives]
• Allow: [Permitted activities within precautions]
• Avoid: [Movements and loads per restrictions]
• Advance when: [Specific measurable criteria]

Phase 2 - Strength & Capacity [Timeframe]:

• Focus: [Primary objectives]
• Allow: [Therex and functional tasks aligned with healing]
• Avoid: [Movements and loads exceeding healing tolerance]
• Advance when: [Measurable criteria]

Phase 3 - Functional Loading/Return [Timeframe]:

• Focus: [Primary objectives]
• Allow: [Progressive impact and multi-planar tasks as cleared]
• Clearance criteria: [Objective tests and thresholds for return to activity/work/sport]

Communication

PT Updates: [Preferred cadence and method for updates]

Next Medical Follow-Up: [Date or timeframe] (Omit if unknown.)

Escalation Triggers: [Milestone failures, red flags, unexpected regression]

Attachments: [Operative report / imaging / protocol] (If referenced but not included, state: "available upon request." Omit if none.)

Referring Clinician Signature: ________________________________

Printed Name/Credentials: [Name, credentials]

Date Signed: [Date]

NPI: [NPI]