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 Home Health Documentation Templates
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Table of Contents Page

Initial Evaluation Summary 3
Daily Note Assessment & Documentation of Treatment 5
Sample Treatment Statements 6
Goal-Setting Template and Examples 7
Progress Note Statements on Goals 8
Discharge Summary Examples 9
Physician Verbal Order Examples and Script Template 10
Objective Measurement Handout 12
Bonus Section: OASIS & PDGM 13
Additional Resources 15

Acronym List
Below is a short list of commonly used Home Health acronyms that you may not have seen in an
outpatient clinic:
ALF: Assisted living facility SBA: Stand By Assist
ADL: Activity of Daily Living SCIC: Significant change in condition
CGA: Contact Guard Assist SOB: Shortness of Breath
DC: Discharge SOC: Start of Care
EOC: End of Care SPC: Single Point Cane
HEP: Home Exercise Program TKA: Total Knee Arthroplasty
LE: Lower extremity THA: Total Hip Arthroplasty
LOB: Loss of Balance UE: Upper Extremity
POC: Plan of Care VC: Verbal cues
ROC: Resumption of Care WBOS: Wide Base of Support
WC: Wheelchair

For a complete list of over 300 common therapy acronyms and abbreviations, visit
https://www.ptprogress.com/common-physical-therapy-abbreviations/​.

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Initial Evaluation Summary (Eval, SOC, ROC)
When documenting your initial evaluation of a new patient, you’ll follow a broad SOAP-note format
popular among PTs. (SOAP stands for Subjective, Objective, Assessment, and Plan.) Generally, you
will use a separate tab to record the Objective measures you took during the evaluation (vital signs,
gait distance, Tinetti score, etc.). See my Objective Measures Handout on page 12.

For the other three sections of your evaluation – Subjective, Assessment, and Plan (Statement of
Need) – you can follow the examples I have below of a brief, initial evaluation summary.

I’ve included subheadings to identify the Subjective / Assessment / Plan within the summaries below.
In your documentation, ​do not include these subheadings as you type your notes..

Evaluation Summary Example 1

(Subjective)
Patient agrees to physical therapy evaluation/ROC. Patient was referred to PT home health due to
muscle weakness and difficulty walking. She suffered a fall on 12/22/20, resulting in R femur fx and R
shoulder dislocation. Patient has other medical hx of afib with rvr, HTN, alcohol abuse, liver problems,
and depression.

(Assessment)
Patient lives in an independent living facility and was independent-mod-independent with ADLs prior
to her fall. Patient presents today with impaired balance and decreased coordination. Patient presents
with independent transfers requiring SBA and VC for safe use of assistive device locking.
Patient has decreased dynamic standing balance to fair – with discontinuous steps when turning in a
circle without hand support and increased postural sway when feet are together. Patient is able to
ambulate 200 feet with FWW and SBA, but demonstrates poor coordination with turning. Her
increased fall risk is evidenced by a Tinetti score of 17/28 and tug at 27.8 seconds. Patient does not
report pain in R shoulder today and has limited use of R arm with reaching and ADLs.

(Plan)
Skilled PT services are warranted to educate patient on HEP, pain mgmt, adequate hydration, energy
conservation and fall prevention strategies, strengthening both LE and UE, improving transfers,
increasing standing balance, and increasing gait and endurance while improving functional mobility to
decrease fall.

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Evaluation Summary Example 2
Patient was seen for an initial PT eval today with POC established. Patient is an 88-year-old female
referred to PT home health due to muscle weakness and compression fracture. Patient has other
medical hx of arthritis of lumbar spine, anxiety, depression, urinary incontinence, osteoporosis,
Vitamin D deficiency, and lung cancer.

Patient lives in an assisted living facility and reported that she has needed more assistance from
caregivers lately. Patient presents with decreased ability to transfer safely, requiring CGA with
multiple attempts to arise from seated position. Patient has decreased dynamic standing balance at
poor+ and needs to hold on to walker for support with CGA to prevent LOB.

Patient is limited with ambulation to 20 ft x 2 with FWW requiring CGA. Impairments in gait include:
decreased step length, inconsistent foot placement, decreased foot clearance into swing phase,
requires a WBOS, and has a decreased cadence. Patient has increased fall risks as evidenced by a
decreased Tinetti score at 9/28 and decreased tug at 42.7 secs. Patient reports vision and hearing
problems and has pain in her low back, rating symptoms at 4/10. Patient also stated SOB after
ambulating 20 ft.

Skilled PT services are warranted to educate patient on fall prevention, energy conservation
techniques, and HEP. Therapeutic treatment will also focus to improve transfers, strengthen both LE,
improve standing balance and address gait impairments to decrease fall risks and to improve
independence with performing ADLs.

Example 3: Recert
Patient is an 84-year-old female referred to PT home health in March of 2020 due to a fall and subsequent
fracture of her right femur. Patient was seen initially on 3/13/20 with POC established.
Patient is being reevaluated by PT today and appears to be regressing in functional mobility. The patient
requires assistance with ADLs, ambulation, bathing, and functional tasks due to lack of strength, balance,
and endurance. The patient will benefit from physical therapy to address impairments of gait and strength
as she ambulates with an uneven and decreased step length, decreased cadence, and poor coordination
with use of FWW. She scored 12 out of 28 on the Tinetti, indicating a high risk of falls.

Skilled PT is needed in order to educate on HEP, safety and energy-conservation techniques; to increase
the strength of her lower extremities and trunk muscles; to improve balance; to increase and improve gait;
and to improve transfers and safety while performing ADLs and functional mobility tasks.

Sample Plan
Skilled PT is recommended twice a week initially for gait training, therapeutic exercise, balance
training, and to provide and progress with an appropriate HEP. On follow-up, continue to progress
with strength training exercises and provide strategies for navigating home environment safely.
Integrate balance training in order to decrease risk of falling.

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Daily Note Assessment & Documentation of Treatment

Some documentation systems require a summary of treatment, including the patient’s response to
treatment. You can document both your treatment and your patient’s response to it using the
following examples as inspiration. While some documentation systems do not include an exact
“objective” or “assessment” section, the examples below satisfy the requirements for justifying and
documenting treatment, as well as recording the patient’s response to treatment.

Example 1
The patient required tactile cueing while performing quad sets, hamstring curls, and SAQ for
increased muscle recruitment, and was only able to reproduce a consistent contraction 50% of the
time without cues. The patient performed each exercise for 10 repetitions: AAROM hip ABD and LAQ
x 10 with right LE, standing heel raises x 10, standing marches x10, and standing hip
abduction/extension with countertop support using both UE x10 each. Max VC required for
performance of exercises with proper technique, avoiding compensation with standing hip
abduction/extension. Instructed patient to do exercises 3x/daily; advised the use of ice to Right hip x
20 minutes while supine with R LE elevated to help decrease swelling. Patient was instructed to stop
the use of ice if non-blanchable redness/blisters are present.

Example 2
The patient agreed to perform the following exercises: seated marching 2x10, LAQ 2x10 bilaterally,
sit-to-stand x5, resisted HS curl with yellow band x10, and resisted ABD with yellow band x10. Verbal
cueing was required 50% of the time to correct LE alignment and to encourage max effort of quad
muscles. The patient experienced a LOB with repeated sit-to-stand and was instructed on the “nose
over toes” strategy to safely rise from a chair. The patient refused to walk more than 15 feet today
with FWW and CGA.

Example 3
The patient was unable to tolerate more than 10 repetitions of therapeutic exercises before
compensating. During the performance of the exercises, the patient required verbal and tactile cueing
for proper performance of standing exercises, which included hip abduction, extension, and marching
x10 bilaterally. The patient will benefit from continued PT to further strengthen the quadriceps and
glutes as well as to progress with balance training and functional activities that decrease fall risk and
improve independence in the performance of his ADLs.

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 Sample Treatment Statements
You can save time writing your documentation by using pre-set treatment statements. For instance,
some work tablets allow you to create predictive typing sequences, like the “Smart Typing” predictive
text option on the Samsung tablet. Adding such pre-assembled sets will allow you to quickly edit
smaller portions instead of typing out each section. Below are a few examples of pre-sets I write
using the predictive text feature whenever I’m in the home health setting.

Seated Exercise Set 1

Seated exercises of 10 repetitions each performed bilaterally including: seated marches, LAQ, ankle
pump heel raises, hamstring curls, knee extension, hip abduction and hip adduction with manual
resistance from therapist.

Seated Exercise Set 2

Seated exercises of 10 repetitions each performed bilaterally with 3# ankle weight including: seated
marches, LAQ, ankle pump heel raises, hamstring curls, knee extension, hip abduction and hip
adduction with yellow resistance band.

Standing Exercise Set 1

Standing exercises of 10 repetitions each performed bilaterally with ue support, gait belt, and CGA
including: heel raises, marches, mini squats, hamstring curls.

Standing Exercises Set 2:

Standing exercises of 10 repetitions each performed bilaterally with ue support, gait belt, and CGA
including: mini squats, hamstring curls, hip abduction, hip flexion, hip extension, lateral stepping.

Balance Exercise Set 1:

Standing balance training for static stabilization using ue support with assistive device: weight shifting
x 10, Romberg stance x10 seconds, Romberg with perturbations x 10 seconds, Romberg stance with
alternating ue reaching x 10 bilaterally, semi-tandem stance with ue support repeated with alternating
stance.

Balance Exercise Set 2:

Single leg stance with ue support of assistive device, 3 point taps with toe to front, side, and behind
x5 with ue support. Therapist provided CGA due to unsteadiness.

Gait Training
Performed gait training with use of FWW; provided cues for safe handling of assistive device, proper
sequencing, and reminders to stay close to device and maintain upright posture.
Patient ambulated _____ feet with _______ device and _______ provided by therapist.

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 Goal-Setting Template and Examples
There are three main elements to an efficient goal: a measurable achievement of a functional ability,
a specific time frame, and the resulting functional impact of the goal.

Goal-Setting Template

The patient will _______ (measurable achievement of functional ability), within ______
(time frame) in order to improve the patient’s ability to ________________ (functional
impact).

Here are some examples of goals I wrote using this template:

Goal-Setting Examples
The patient will demonstrate independent ambulation with a FWW on level surfaces up to 500’ within
3 weeks in order to safely walk to the dining hall independently.

The patient will demonstrate increased Right shoulder flexion AROM to greater than 110º within 4
weeks in order to improve the ability to reach into overhead cabinets at home.

The patient will demonstrate increased strength to R LE to 4+/5 by discharge in order to transition
safely from a seated position to ambulate with assistive device.

The patient will ambulate 1200’ independently with FWW in 4 weeks in order to safely navigate the
facility to access the dining room at meal times.

The patient will achieve 90º of knee flexion AROM in 2 weeks in order to rise from a chair with proper
LE support and alignment.

The patient will demonstrate independence with Right TKA home exercise program within 2 visits and
standing program within 5 visits in order to progress to an outpatient therapy setting.

In 1 week, the patient will demonstrate safe, independent ability to transfer from a supine to a sitting
position, while maintaining hip precautions, in order to facilitate dressing tasks.

In 3 weeks, the patient will demonstrate the ability to ascend/descend 12 steps independently with
use of one handrail in order to navigate to the basement to perform laundry tasks.

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Progress Note Statements on Goals

Some documentation systems require a separate line for a statement of progress on goals instead of
including it in the assessment. Below are examples of ways to comment on a patient’s progress in
case you must document a separate progress note.

Example Statements on Goals

The patient can now perform bed mobility tasks independently, as glute and quad strength has
increased beyond 3/5 MMT grade.

The patient reports the ability to reach to head level now, providing greater independence in the
ability to perform grooming tasks.

The patient can tolerate sitting for 15 minutes now independently, facilitating the ease of bathing as
he requires assistance with bathroom tasks.

The patient is now able to ambulate 75’ (half the distance to the dining hall) on a carpeted floor with
SPC and SBA before regression of foot clearance.

The patient has achieved the goal to ambulate 250’ independently but continues to experience SOB,
which is limiting the ability to perform required activities such as holding his food tray and navigating
the dining hall independently. Further gait training and cardiovascular endurance training are required
to decrease the risk of fall.

The patient is now pain-free while walking; however, the patient is at risk of falling due to poor quality
of gait. Continued treatment will focus on improving consistent heel strike and foot placement, which
should allow the patient to achieve a safe level of independence at home with an assistive device.

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 Discharge Summary Examples

Example 1
Patient is discharged from therapy because her strength and balance goals have been met. She will
continue to receive care for the wound on her right leg, but she reports that it has been doing much
better since the last few bandage changes. She will continue to ambulate with FWW to meals with
assistance from aide, using a WC to follow behind her to provide assistance when fatigued. She
verbalized commitment to continue performing her home exercise program and was very grateful for
the excellent care provided by PT/OT/nursing staff​ .

Example 2
Patient is discharged from physical therapy today. She remains dependent on caregivers to assist
with transfers, bathing, and functional ADLs. She can use her walker to ambulate; however, she is
adamant about not wanting to walk due to pain and her disdain towards the walker. Her balance is
poor and she requires mod-to-max assist with transfers. She will need continued assistance for daily
tasks and was instructed to always call for help when she needs to get out of bed.

Discharge Statement on Goals

The patient has met the goals established at the start of care. The patient verbalizes and
demonstrates safe use of assistive device and is able to ambulate with SBA over 250’ on variable
surfaces. The patient demonstrates improved balance as noted by greater ability to stand at a
countertop safely to prepare small meals. Patient fall risk has decreased as noted by the improved
Tinetti score, with areas of standing balance and gait stability improving the most. The patient
verbalizes the importance of requesting assistance from support staff in order to transfer to the
bathroom at night. Due to the patient’s history of memory impairments and deficits in recall, it is
recommended that the patient continue to have assistance with ambulation outside of her room and
with functional ADLs such as bathing, toileting, and meal preparation.

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 Physician Verbal Order Examples & Script Template

How to Obtain and Document Verbal Orders:

Call the number of the physician on file; use the script below; and record the orders in your
documentation system.

“Hi my name is __________, I’m a _________ Therapist requesting verbal orders to start care for
Dr. ______’s patient __(name)____, ___(DOB____. “ (If leaving a message, continue with… “Please
return my call as soon as possible with verbal orders approving the evaluation/ recertification of the
patient __(name)___, __ (DOB)____. My cell # is ________. Thank you.”)

If a medical assistant or nurse answers, simply use the first half of the script above. Be sure to
retain their name, title, and the time the call was made.

You should keep records of the calls you make for physician orders; even a sentence or two can be
enormously helpful for your documentation. Take a look at my examples below.

Verbal Order Examples:

Called Dr. Smith’s office today at 11:21 am and spoke with Karen (medical assistant) and received
verbal orders for PT POC.

Called and left a message with the patient’s orthopedic physician, Dr. Jones today at 1:48 pm to
request for approval for PT POC today following TKA.

Second call was placed today to Dr. Jones’ office at 12:32 pm. Spoke with his nurse John who
relayed the approval of verbal orders to begin PT POC.

Called Dr. Murray’s office today at 8:49 AM. Spoke with nurse/MA Susan who confirmed approval of
the physician’s verbal order to start/resume PT/OT care.

Physician Order: Organization Tip

Keeping track of verbal orders made, received, and outstanding can be a challenging part of your job.
Create a flowsheet or print the following verbal order tracking sheet to stay organized.

Patient’s SOC/ROC Physician ✓ Orders Rec’d Left msg ? Comments

Initials Date Name by: ​(name) (time/date) (hr:mm) PM

G.L 1/2/21 Dr. Jones Sue MA 1/2/21 0900 1/2/21 0830

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Physician Order Tracking
Patient’s SOC/ROC Physician ✓ Orders Rec’d by: Left msg ? Comments
Initials Date Name (name) (time/date) (time)/date

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OBJECTIVE MEASURES

Postural Assessment & Symptom Location

Vital Signs

Joint ROM
Joint Left Right Comments

Muscle Tests
Muscle Left Right Comments

Special Tests:

Balance Testing:

Gait & Functional Movement Tests:

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 Bonus Section: OASIS & PDGM
Medicare requires all home health assessments to follow the patient-specific standards of OASIS,
which stands for Outcome and Assessment Information Set. The OASIS assessment tool exists to
provide a standardized way of collecting information on a home care recipient’s demographics,
clinical status, functional status, and overall service needs. (Visit CMS.gov for more details.)

New PDGM Rules for 2020

On January 1, 2020, a new policy went into effect, requiring home health agencies to follow the
Patient-Driven Groupings Model. The PDGM sets a “base-rate” payment for reimbursement and
adjustments based on each patient’s case-mix factors, such as their diagnosis and functional
impairments. The patient’s OASIS and claims data will inform these PDGM adjustments.

As a home health therapist, it’s important to understand how to correctly score the OASIS. Multiple
factors are used to calculate the new, functional PDGM changes.

Of these new changes, one of the biggest is that Medicare now provides therapy agencies one
payment to cover 6 services within a 30-day period. These services include skilled nursing, home
health aide, PT, OT, Speech Language Pathology, and medical social services.

Efficiency in OASIS Completion

Completing an OASIS can be very confusing for a new home health professional. While the goal of
this template is to share insight and provide examples of well-written home health therapy
documentation, it cannot substitute the OASIS/PDGM training most therapists need to become
efficient in this area.

The reason I included this additional section to cover OASIS/PDGM is

to introduce a separate training module I’ve relied on for my
documentation. This training module is very thorough in explaining
how to ​efficiently​ and ​accurately​ complete the OASIS data in the
new PDGM environment.

I personally use and recommend the ​MedBridge OASIS and PDGM

courses​ because they are easy to follow and are taught by the leaders
in OASIS/PDGM training. Through MedBridge, you can both access
this training and complete your annual continuing education requirements. Use the discount code
“PTProgress” for a $175 discount, lowering the entire MedBridge Education library of courses to just
$200. I’ve saved well over $200 a year because of these MedBridge courses. Home health therapists
who are paid per patient visit will also save hours of documentation time each week from this training!

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Time-saving Handouts and Resources

Printable PDFs of stick-figure exercise 

progressions that are large, easy to follow, 
and effective! You get 7 templates with over 
40 exercises included. 
 
If you spend even 3 minutes drawing or 
writing out exercises, these handouts can 
save you 15 minutes a day.  

 
7 PDF Handouts to include: 

● Seated Exercises 
● Standing Exercises (Basic and 
Advanced) 
● Balance Progression 
● Shoulder Exercises 
● Total Knee Replacement Exercises  
● Total Hip Replacement Exercises 

Over 40 Exercises! 

Each handout includes individual exercises 

that are easy to follow and simple to 
understand.   

Get the Handouts at: 

https://www.ptprogress.com/stickfigure  

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Time-Saving Handouts and Resources

Therapy Evaluation Templates Save $175 on ​MedBridge

Speed up your evaluations with the therapy with Promo Code: “PTProgress”
evaluation templates. Learn ways to improve your
efficiency as you type your evaluation. Includes
full text examples and evaluation templates to use
in the clinic.

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FREE Continuing Ed Tracker:

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