Pulmonary Rehabilitation Initial Evaluation & Individualized Treatment Plan

Patient Name: [Patient full name] MRN: [Medical record number] DOB: [Date of birth]

Date/Time of Evaluation: [Date and time] Location: [Facility/site] Modality: [in-person / telehealth]

Evaluator: [Name, credentials, discipline]

PR Attending Physician: [Physician of record overseeing PR]

Referring Clinician: [Name, credentials] Referral Date: [Date]

Primary PR Indication: [Qualifying diagnosis prompting referral]

Program Start Date: [Date] Planned Duration: [Duration in weeks] Planned Sessions: [Number of sessions]

(Do not infer disease severity, oxygen requirements, adherence, smoking status/readiness, or safety to exercise without documented basis. If any required element is unavailable, explicitly document as "Not available at intake—requested from [source]" or "Deferred due to [reason]; will complete by [date]." Omit optional sections entirely if not applicable—do not insert normal defaults.)

Reason for PR / Chief Concern

[Primary functional limitations and patient-stated goals] (Summarize in 1–3 sentences. Include a direct patient quote when available.)

History & Baseline Context

Pulmonary history: [Primary diagnosis with phenotype and severity markers; baseline symptom pattern; exacerbation history with recent hospitalizations/ED visits; current respiratory supports including oxygen settings for rest/exertion/sleep, NIV/CPAP, airway clearance regimen; safety-relevant history including syncope, exertional chest pain, arrhythmias, falls, panic with dyspnea] (Specify source—patient report vs records—when relevant.)

Comorbidities and precautions: [Cardiac conditions; musculoskeletal limitations; metabolic conditions; cognitive impairment; fall risk factors; contraindications or precautions for exercise testing]

Medications: [Respiratory medications with dosing; adherence notes; inhaler technique concerns; high-risk medications affecting exercise tolerance] (Do not infer adherence; document as unknown if not confirmed.)

Tobacco/nicotine and exposures: [Current status with pack-years; quit attempts and readiness; occupational/environmental exposures] (If unknown, state unknown and plan to assess.)

Social/functional context: [Living situation and caregiver support; transportation; work/role status; baseline activity level and assistive devices; barriers to attendance]

(If any required information is missing, document what is missing and the plan to obtain it.)

Baseline Objective Data

Vitals: [Resting BP, HR, RR, SpO2 with oxygen setting if applicable, weight, BMI]

Focused exam findings: [General appearance; work of breathing; lung sounds; peripheral edema; gait/balance observation] (Include only if exam performed; omit this paragraph entirely if no exam was performed.)

Key Diagnostics: [PFTs with date: FEV1, FVC, FEV1/FVC, DLCO, percent predicted if available] [Relevant imaging summary with dates] [Sleep study findings if applicable: AHI, nocturnal hypoxemia, PAP settings] [Other relevant completed tests with dates] (For missing diagnostics informing exercise safety, note as "Requested/Pending" with plan to obtain.)

Baseline Functional Assessment

Exercise Performance

• Test: [Standardized test name and protocol]
• Performance: [Distance/work achieved, total time, number and duration of rests with reasons]
• Pre-test: [BP, HR, SpO2 with O2 setting, dyspnea rating, leg fatigue rating] (Specify scales used.)
• During test: [SpO2 trajectory and nadir with timing, HR response, symptoms/events, oxygen device and flow with any titration]
• Post-test: [BP, HR, SpO2 at 1–3 min recovery, recovery symptoms]
• Safety events: [Any termination criteria met or safety events] (Document rationale for early termination if applicable.)

Self-Reported Measures

Dyspnea Score: [Instrument, score, date, completion method: self / assisted]

Quality of Life Score: [Instrument, score, date] (Include only if obtained.)

Behavioral Baselines

[Smoking status and details; oxygen utilization pattern for rest/exertion/sleep and adherence per patient report or device data; home physical activity pattern and average weekly minutes with assistive devices used] (If unknown, state unknown with measurement plan.)

Psychosocial Assessment

• Mental/emotional functioning: [Depression and anxiety screening scores with dates; panic related to dyspnea; fear-avoidance behaviors; motivation/readiness]
• Family/home situation: [Caregiver support; home environment constraints; safety concerns; transportation barriers] (Required element per Medicare.)
• Learning readiness: [Cognitive barriers; language needs; hearing/vision barriers; interpreter use]
• Referrals: [Criteria met for behavioral health or social work referral and actions taken] (If screening not completed, document reason and plan.)

Education Needs Assessment

[Baseline knowledge gaps and misconceptions; preferred learning method; cultural or language needs impacting education]

Safety Considerations

• Fall risk: [low / moderate / high] Mobility assistance: [Assistance needs during sessions]
• Oxygen monitoring during exercise: [continuous / intermittent] [Monitoring intervals and device]
• Individualized stop criteria: [Chest pain threshold; dizziness/syncope; severe dyspnea; desaturation threshold; hypertensive response threshold; other patient-specific criteria]
• Equipment needs: [Assistive device; portable oxygen; pulse oximeter; other]

(If safety data incomplete, document conservative precautions and plan to complete evaluation.)

Assessment Summary

[Clinical synthesis explaining why PR is indicated now, baseline limitations, and rehabilitation potential] (Base interpretations on documented measures only.)

Problem List:

1. [Problem mapped to ITP intervention]
2. [Problem mapped to ITP intervention]
3. [Problem mapped to ITP intervention]

(Add or remove items as clinically appropriate.)

Individualized Treatment Plan

ITP Effective Date: [Date] Next Scheduled Review: [Date, approximately 30 days per Medicare requirement]

Diagnosis: [PR qualifying diagnosis with severity markers]

Exercise Prescription

• Aerobic training: [Mode(s); intensity target method with RPE and/or dyspnea rating range, HR range if appropriate; initial duration per session; progression plan; frequency including PR sessions per week and home exercise days; warm-up and cool-down parameters]
• Resistance training: [Muscle groups; sets/reps; intensity guidance; progression plan]
• Breathing/respiratory techniques: [Techniques to be taught; practice frequency] (Include only if indicated.)
• Oxygen during exercise: [Device and flow for rest vs exertion; SpO2 target threshold; monitoring method; titration plan] (Include only if applicable.)
• Safety limits: [Individualized stop criteria; clinician notification triggers]

Education Plan

• [Respiratory self-management and action plan use]
• [Exacerbation recognition and response]
• [Medication management and inhaler technique]
• [Breathing strategies and energy conservation]
• [Oxygen equipment and safety] (If oxygen user.)
• [Smoking cessation counseling or referral] (If current smoker.)
• [Home exercise planning and progression]
• [When to seek urgent/emergency care]

(Specify delivery method for each: individual/group, verbal/written/demonstration, teach-back.)

Psychosocial Plan

[Coping and stress management interventions; referrals placed or planned; attendance barrier mitigation strategies; plan for repeating screening measures]

Outcomes Assessment Plan

[Exercise performance measure and timeframe; dyspnea measure and timeframe; QoL measure and timeframe if used; behavioral measures to repeat; goal attainment tracking method and schedule]

Goals

• [Objective exercise tolerance goal with measurable target and timeframe]
• [Dyspnea/symptom goal with measurable target and timeframe]
• [Functional goal related to ADLs or ambulation with measurable target and timeframe]
• [Education competency goal(s) with teach-back criteria and timeframe]

(Use SMART format and patient language where possible. Include 2–5 goals.)

Plan Logistics & Referrals

Planned PR schedule: [Days per week, expected completion timeframe]

Referrals placed: [PT, OT, dietitian, behavioral health, smoking cessation, social work, other as applicable]

Communication to referring clinician: [Summary sent, date/method]

Equipment needs identified: [Home pulse oximeter, portable oxygen, assistive device, other]

Physician Review & Attestation

Initial ITP Review

Physician Name: [Name]

Signature: [Signature] Date/Time: [Date and time]