Therapy Evaluation Note (Home Health)

Patient: [Patient name], [DOB], [MRN / Agency ID]

Date of Visit: [Date] [Start time–Stop time] (Include times if required by agency)

Visit Type: Initial Therapy Evaluation

Discipline/Clinician: [PT / OT / SLP], [Clinician name, credentials]

Location: [Residence type and setting]

Referring Provider: [Provider name]; Ordering Diagnosis: [Diagnosis]; Referral Date: [Date]

Episode Context: Start of care [Date]; [Recent hospitalization / SNF stay with dates, if applicable]

Precautions: [Weight-bearing status / Fall precautions / Aspiration precautions / Cardiac precautions / Lines or tubes / Infection control / Other] (List only those that apply)

Reason for Visit

[Reason for evaluation linked to referral and functional problem, including onset and context] (If multiple concerns, list in descending safety/acuity priority)

Subjective

Patient Goals and Priorities: [Patient-stated functional goals in their own words] (Include caregiver goals if different; note alignment or conflicts; use source attribution)

Prior Level of Function: [Baseline function immediately prior to current illness/injury: devices used, assistance level, mobility, ADLs/IADLs; for SLP include communication/swallowing baseline] [Pertinent medical/surgical history and comorbidities impacting therapy] [Falls history over past 12 months including injuries and circumstances] [Prior therapy services and response] (Use source attribution throughout; if unknown, state "Unknown—patient unable to recall" or "Not available—no caregiver present")

Home Situation: [Living arrangement], [Caregiver availability in hours per day], [Caregiver willingness and identified training needs], [Environmental factors: stairs, bathroom setup, bedroom location, access barriers] (If information limited, state plan to obtain collateral)

Current Symptoms: [Pain location, intensity, and functional impact], [Dizziness/orthostasis], [Dyspnea], [Fatigue], [Fear of falling]; for SLP: [Communication complaints], [Swallowing symptoms], [Diet changes], [Coughing/choking history] (Quantify when possible)

Medications: [Source of medication list], [Therapy-relevant observations: sedation, hypotension symptoms, adherence barriers] (Focus on items affecting participation and safety rather than full medication list)

Objective

Vitals/Physiologic Response: [Resting vitals], [Orthostatic vitals if indicated], [Exertional response during key tasks with recovery time], [Adverse responses observed]

Cognition and Communication: [Arousal, attention, orientation], [Safety awareness], [Ability to follow commands and learning readiness], [Communication barriers and interpreter use if applicable], [Mood or behavior impacting participation]

Systems Review and Impairments: (Focus on findings that drive the plan; omit subsections not relevant to the discipline)

• PT/OT: [Functional ROM and strength], [Tone], [Coordination], [Balance—static and dynamic], [Endurance], [Pain with movement]
• SLP: [Oral-motor exam], [Voice and speech intelligibility], [Clinical swallow exam elements]

Functional Performance: (Document tasks observed with task name, assistance level, device/adaptive equipment, cueing type and frequency, safety observations, quality descriptors)

• PT minimum domains: [Bed mobility], [Transfers], [Gait with distance], [Stairs]
• OT minimum domains: [Transfers], [Bathing], [Dressing], [Toileting], [Grooming], [Key IADLs]
• SLP minimum domains: [Functional communication], [Diet level], [Swallowing safety]

Standardized Outcome Measures: (If measure not performed, document rationale: safety concern, patient refusal, or time constraints)

Measure Name	Test Conditions (device, assistance, surface)	Score (units)	Interpretation
[Measure name]	[Test conditions]	[Score and units]	[Interpretation if used locally]
[Measure name]	[Test conditions]	[Score and units]	[Interpretation if used locally]

Home Environment and Safety: [Entry method with steps and railings], [Primary pathways], [Floor hazards], [Lighting], [Bathroom safety features: grab bars, toilet height, tub/shower type], [DME present and condition], [Emergency preparedness: phone access, ability to summon help]

Caregiver Assessment: [Caregiver present / not present], [Observed ability to assist safely including body mechanics and cueing effectiveness], [Training needs identified], [Teach-back results] (If no caregiver present: "No caregiver present; plan training session next visit." If no caregiver available: "No caregiver available; patient responsible for self-management.")

Assessment

Clinical Summary: [2–5 sentence synthesis of baseline versus current function, key impairment drivers, and primary safety risks]

Problem List: (Prioritize in descending order of risk and impact)

• [Problem 1]
• [Problem 2]
• [Problem 3]

Skilled Need: [Explicit rationale for skilled therapy: clinical judgment required for safe progression, skilled instruction for compensatory strategies, caregiver training needs, objective measurement and reassessment requirements]

Prognosis: [Expected trajectory and timeframe], [Contributing factors: motivation, cognition, caregiver support, comorbidities] (For maintenance therapy, state realistic expected outcome)

Homebound Status Support: [Specific observations describing why leaving home is taxing or requires assistance] (Include only if applicable; use fact-based statements rather than conclusory language)

Coordination Needs: [Recommendations for other disciplines: RN, MSW, aide, dietitian], [Physician follow-up needs], [DME recommendations], [Community resources], [Red flags requiring escalation]

Goals

(Write functional, measurable goals: task, assistance level/device, measurable metric, timeframe, safety criterion; align at least one goal to standardized baseline measure)

• [In timeframe], patient will [functional task] with [assistance level/device], [measurable criterion], [safety element].
• [Goal 2]
• [Caregiver training goal if applicable]

(If goals cannot be finalized due to fatigue or missing caregiver: document interim goals and "Plan to finalize next visit.")

Plan

Visit Frequency and Duration: [Frequency] for [Duration] (e.g., 2x/week for 4 weeks)

Interventions:

• [Therapeutic exercise with progression approach and target impairments]
• [Balance and gait training with skilled components]
• [ADL retraining / transfer training] (OT)
• [Swallow therapy / cognitive-communication strategies] (SLP)
• [Caregiver training plan]
• [Home safety modifications and DME recommendations]

Education Provided: [Topics taught], [Method: demonstration / teach-back / written materials], [Patient and caregiver response], [Barriers addressed]

Home Program: [Exercises and strategies initiated], [Dose: sets, reps, frequency], [Equipment needed], [Safety constraints], [Patient performance and cueing required today], [Adherence plan and progression criteria]

Discharge Planning: [Anticipated discharge criteria: goal attainment, safe self-management, caregiver competence], [Anticipated next setting or resources]

Coordination and Communication

[Physician/practitioner communication completed or planned], [Interdisciplinary coordination], [Urgent notifications if applicable]

Signature

[Clinician signature], [Credentials], [Date and time authenticated]