Plan of Care (Athletic Therapy Rehabilitation)

Patient: [Name] | [DOB] | [MRN/ID] | [Sport/Team]

Episode: [Date of injury/onset] | [Surgery date] | [Body region/side]

Clinician: [Name], [Credentials], [Organization]

Plan Status: [Initial / Updated / Recertified] | Date established: [Date] | Next review due: [Date]

Clinical Summary

• [Primary diagnosis with stage: acute/subacute/chronic, post-op day/week if applicable]
• [Mechanism of injury: contact/non-contact and contextual factors]
• [Key exam or imaging findings driving precautions and progression]
• [Sport/position demands and competition timeline]
• [Relevant history or comorbidities affecting rehab]
• [Barriers or facilitators: equipment access, schedule constraints, psychosocial factors]
• (If critical information such as post-op restrictions is unknown, document: "Progression limited until restrictions confirmed." Do not infer restrictions.)

Problems & Baseline Assessment

(List problems in descending clinical priority. Include baseline metric, irritability behavior, and priority rationale for each significant problem. Omit categories without findings.)

Impairments

• [Pain] — [Location/pattern], [Scale], [Baseline score]; Irritability: [Aggravating/easing factors, time to baseline]; [Priority rationale]
• [Effusion/Swelling] — [Region], [Grade/circumference measure]; Irritability: [Behavior with activity]; [Priority rationale]
• [ROM deficits] — [Joint/plane], [Baseline AROM/PROM values], [End-feel if relevant]; [Priority rationale]
• [Strength deficits] — [Muscle group/movement], [Testing method], [Baseline value and limb symmetry index]; [Priority rationale]
• [Neuromuscular control/proprioception deficits] — [Description and baseline test]; [Priority rationale]
• [Tissue irritability/load tolerance] — [Acceptable pain thresholds and 24-hour response pattern]

Activity Limitations

• [Functional task: squatting/stairs/running/cutting/landing/throwing] — [Baseline capacity/quality], [Symptom threshold and recovery time]; [Priority rationale]

Participation Restrictions

• [Practice limitations] — [Drills/segments restricted], [Workload/volume limit]
• [Competition status] — [Cleared / Not cleared / Modified], [Role-specific limitations]

Outcome Measures & Reassessment Plan

• [Region-specific PROMs] — [Instrument names], [Baseline scores], [Reassessment cadence]
• [Functional performance tests] — [Tests planned], [Baseline values], [Reassessment schedule] (If deferred due to acuity, state when they will be obtained.)

Goals

Athlete-stated goal: [Quote or paraphrase of athlete's primary objective]

Short-Term Goals (1–4 weeks)

• [Specific behavior/ability] — Baseline: [Value]; Target: [Value]; Timeframe: [Weeks]; Conditions: [Pain threshold, technique standard, recovery time]
• [Specific behavior/ability] — Baseline: [Value]; Target: [Value]; Timeframe: [Weeks]; Conditions: [Criteria]

Long-Term/Discharge Goals

• [Functional/participation outcome] — Baseline: [Value]; Target: [Value]; Timeframe: [Weeks or date]; Conditions: [Quality standards]
• [Functional/participation outcome] — Baseline: [Value]; Target: [Value]; Timeframe: [Weeks or date]; Conditions: [Criteria]

Return-to-Sport Criteria (Objective thresholds required for clearance.)

• [Test/metric] — Target: [Threshold]; Conditions: [Pain limit, quality standards, symmetry requirement]
• [Test/metric] — Target: [Threshold]; Conditions: [Criteria]

Treatment Plan

Frequency & Duration

• Supervised sessions: [Sessions/week] for [Duration in weeks]; Tapering plan: [Description]
• Home program: [Days/week], [Sets/reps or time], [Progression rules]
• Discharge target: [Anticipated date or criteria-based triggers]

Precautions & Contraindications

• [Medical restrictions] — [Weight-bearing status, ROM limits, brace requirements, surgical protocol]
• [Tissue irritability rules] — Stop/regress if: [Pain threshold], [Swelling threshold], [24-hr symptom escalation], [Compensatory movement]
• [Red flags requiring referral] — [Neurovascular changes, infection signs, DVT symptoms]
• (If restrictions are unknown, document: "Progression limited until clarified with surgeon/physician.")

Staged Progression (Document current and upcoming phases with criteria-based advancement.)

Current Phase: [Phase name]

• Primary objectives: [Objective 1]; [Objective 2]; [Objective 3]
• Allowed activities: [Permitted tasks/loads/intensities]
• Restricted activities: [Restrictions aligned with precautions]
• Key interventions: [Mobility, Strengthening, Neuromuscular control, Conditioning, Manual therapy, Modalities]
• Exit criteria: [Objective thresholds required to advance]
• Regression criteria: [Findings requiring step back]

Upcoming Phase: [Phase name]

• Primary objectives: [Objectives]
• Allowed activities: [List]
• Restricted activities: [List]
• Key interventions: [List]
• Exit criteria: [Objective thresholds required to advance]
• Regression criteria: [Findings requiring step back]

Planned Interventions (Link to specific problems. Omit unused categories.)

• Therapeutic exercise: [Mobility targets], [Strengthening: movements, dosage], [Conditioning: mode, intensity, duration]
• Neuromuscular re-education: [Balance/proprioception], [Movement mechanics], [Sport-specific drills], [Cueing strategies]
• Manual therapy: [Target tissues/joints], [Techniques], [Rationale]
• Modalities: [Purpose], [Type], [Parameters] (Only include if indicated.)
• Taping/Bracing: [Type/purpose], [Wear schedule], [Weaning plan]
• Education: [Load management], [Self-monitoring], [Symptom response rules], [RTS expectations]
• Home Exercise Program: [Exercises], [Dose], [Progression rules], [Adherence plan]

Monitoring & Discharge

• Reassessment schedule: [Re-evaluation cadence], [Phase-transition testing points]
• Progress measures: [Pain scale, ROM, Strength, Functional tests, PROMs, Workload monitoring]
• Plan modification triggers: [New diagnosis, Surgery, Major regression, New restrictions, Adverse events]
• Discharge criteria: [Goal attainment], [Independent self-management], [Return-to-sport completion], [Plateau with rationale]
• Post-discharge plan: [Maintenance program], [Injury prevention], [Follow-up schedule]