Therapy Prescription & Plan of Care (PT/OT/SLP)

Patient: [Full name], DOB: [Date of birth], MRN: [Medical record number]

Contact/Address: Phone: [Phone number]; Address: [Street, City, State, ZIP] (Include address for home-based services.)

Communication Needs: [Preferred language, interpreter needs, AAC requirements] (Include only if applicable; otherwise omit this line.)

Referring Provider: [Name], [Credentials], NPI: [NPI], Practice: [Practice name], Phone: [Phone], Fax: [Fax]

Date of Referral: [Date]

Reason for Referral: [One-line summary of why therapy is needed]

Therapy Destination: [Clinic or agency name], Setting: [outpatient clinic / home-based / telehealth]

Payer/Authorization: [Payer type]; [Authorization requirements or visit limits] (Omit this line if unknown.)

Plan Dates: Start: [Plan start date]; Anticipated End: [Anticipated end date]; Recert Due: [Recertification due date] (If uncertain pre-evaluation, state "To be established at initial evaluation.")

Status: [Draft—missing required plan elements / Final] (Mark as Draft if diagnoses, goals, or treatment parameters are missing.)

Clinical Indications

Primary Diagnosis (ICD-10): [ICD-10 code] — [Brief descriptor, laterality, surgery date if applicable]

Therapy Problem Areas: [Functional domains requiring therapy, aligned to ordered disciplines] (e.g., mobility limitation, balance deficit, ADL limitation, upper extremity dysfunction, dysphagia, cognitive-communication impairment, voice/speech/language disorder)

Clinical Summary: [Onset/injury/surgery date, mechanism if relevant, comorbidities affecting safety or progression, relevant medications, prior functional level, current living situation] (Keep to a few sentences; include only information that directly affects therapy decisions.)

Medical Necessity Statement: [Why the condition causes functional limitation; why skilled therapy is required rather than unskilled exercise; expected course: restorative improvement / maintenance / decline prevention]

Precautions and Restrictions

(Be explicit and unambiguous. Do not infer restrictions. Include only categories that apply.)

General Safety: [Fall precautions, cardiac precautions, orthostasis risk, lines/tubes, implant/device precautions, skin integrity concerns, seizure precautions] (List all that apply.)

Orthopedic/Post-op Restrictions: [Weight-bearing status with limb specified; ROM restrictions in degrees and planes; sling/brace requirements; lifting limits in lbs or kg; prohibited movements or tendon precautions] (List all that apply; omit this category if none.)

Swallowing/Diet Restrictions: [Diet texture, liquid consistency, aspiration precautions, supervision requirements during meals] (Include for SLP cases; omit if not applicable.)

Cognitive/Behavioral Considerations: [Safety considerations affecting therapy sessions] (Omit if none.)

Clarification Statement: [Restrictions not provided—clarification required prior to high-risk interventions. / No additional precautions beyond standard therapy safety screening.] (Use first option if restrictions are missing but clinically expected; use second option if truly no precautions apply.)

Plan of Care by Discipline

(Repeat the following subsection for each ordered discipline. Include only disciplines being ordered.)

[Physical Therapy / Occupational Therapy / Speech-Language Pathology]

Treating Clinician: [Name, credentials] (State "To be assigned" if unknown.)

Therapy Diagnoses: [Discipline-specific diagnoses or problem focus areas]

Baseline Functional Status: [What the patient cannot do or cannot do safely; objective measures with test name, score, and date] (If pre-evaluation, state "Baseline to be established at initial evaluation.")

Patient Priority: [Brief patient-stated goal] (Omit if not available.)

Long-Term Goals:

• [Measurable functional goal: functional activity, assistance level/device, quantitative target, timeframe, conditions] (Group by functional domain if multiple goals. Each goal must be measurable and functional.)

Short-Term Goals:

• [Intermediate measurable milestone toward long-term goals] (Recommended but not required; omit section if none specified.)

Planned Interventions: [Intervention categories] (e.g., therapeutic exercise, gait training, balance training, manual therapy, ADL training, dysphagia therapy, cognitive-communication strategies, patient/caregiver education, home exercise program. Label as "anticipated" if pre-evaluation.)

Treatment Parameters:

• Type: [Discipline and primary intervention focus]
• Amount: [Sessions per day]
• Frequency: [Sessions per week]
• Duration: [Number of weeks or total visits]
• Taper Plan: [Frequency reduction over time] (Omit if not applicable.)

(Label as "Therapist recommendation pending provider approval" if provider sign-off is required.)

Equipment/Devices: [Current assistive devices, orthotics, DME; recommended devices with justification] (Omit if none.)

Home Program/Caregiver Training: [Home program plan, caregiver training needs, adherence barriers] (Omit if not applicable.)

Reassessment Plan: [Reassessment interval, criteria for plan modification or discharge, timing for provider updates]

Certification and Signatures

Established By: [Name], [Credentials], [Role: therapist / physician / NPP]

Signature: ______________________________ Date: ______________

Provider Certification: [Date and method plan was transmitted to referring provider] (If no order exists or payer requires physician signature, include signature line below.)

Physician/NPP Signature: ______________________________ Date: ______________

Recertification Due: [Date] (If revised plan with significant goal changes, indicate "Revised Plan of Care" with new effective date.)