Physical Therapy Initial Evaluation Basics #web #based #physical #therapy #documentation


Posted On Aug 11 2017 by

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Posted By: David Mangusan Jr, BSPT, PTRP

The physical therapy initial evaluation (I.E.) is a documentation employed by physical therapists (PT) during the first encounter with a patient or client. It is sometimes called “initial examination” or “initial examination/evaluation.” This physical therapy documentation is usually completed in one visit. Usually, evaluation takes about 30 minutes.

Included in the PT initial evaluation or examination are the following:

This includes information obtained from history, review of systems, PT diagnostic tests and measurements.

Here, the level of impairment, activity or mobility and any participation restriction is indicated as determined by the physical therapist.

This part may include documentation of the predicted level of improvement (goals) that may be attained through the proposed treatment interventions. It also includes the duration or amount of time required to reach those goals. Prognosis documentation is usually included in the plan of care and is not necessarily a separate document. (See plan of care below)

The plan of care of the initial evaluation or examination is usually stated in general terms. It includes the goals, which are stated in measurable terms; planned treatment interventions; proposed frequency and duration of therapy required to attain the goals; and discharge plans as determined by the therapist.

The plan of care in the I.E. is based on the specific problems of your client. Often, it is related to the results of the examination.

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Suggested Readings:

  • Physical Therapy Documentation
  • Writing Physical Therapy SOAP Notes (PT Notes) Basics
  • Physical Therapy Notes Writing Guidelines
  • Parts of the Physical Therapy SOAP Notes

Reference:
American Physical Therapy Association (APTA). Guidelines: Physical Therapy Documentation of Patient/Client Management, available at http://www.apta.org. Accessed on June 30, 2010.

Disclaimer: The information obtained on Physical Therapy Notes (PT Notes) is not intended as a substitute for medical professional help or advice but is to be used only as an aid in understanding physical therapy and physical therapy treatments. A qualified physical therapist or physician should be consulted for any neuro-musculoskeletal problem prior to self-treatment. This website provides links to other organizations and websites as a service to our readers and is not responsible for the information, services, or products provided by these web sites, health professionals, or companies. The owners of this website accept no responsibility for the misuse of information contained within this website.

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Last Updated on: August 11th, 2017 at 12:12 am, by


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