Physical therapy evaluation form
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This document contains codes, abbreviations, and assessment information for a physical therapy patient. It includes codes for things like weight bearing status, mobility assistance levels, and equipment used. There are sections assessing the patient's bed mobility, transfers, gait, balance, range of motion, strength, and safety awareness. Short and long term treatment goals are listed, along with plans for bed mobility training, transfer training, gait training, and balance training. The rehabilitation potential and plans for continued treatment are also summarized.
Physical therapy evaluation form
- 1. CodesNT NA I S SBA = Not Tested = Not Applicable = Independent = Supervised = Stand By Assist CGA Min. A Mod. A Max. A U = Contact Guard Assist = Minimal Assist = Moderate Assist = Maximum Assist = Unable WBAT PWB TTWB NWB = Weight Bear as tolerated = Partial Weight Bearing = Toe Touch Wt. Bearing = Non-Weight Bearing Equipment HW = Hemiwalker CR = Crutches SW = Standard Walker SPC = Single Point Cane FWW = Front Wheel Walker NBQC= Narrow Base Quad Cane 4WW = Four Wheel Walker WBQC= Wide Base Quad Cane WC = Wheelchair Functional Status Bed Mobility Assist Transfers Assist Transfers Assist Transfers Assist Rolling Right Supine - Sit Stand - Sit Toilet Rolling Left Sit - Supine Bed - WCSit - Scooting Sit - Stand WC - Bed Balance Sitting Standing Gait Static Equipment Distance (Feet) Dynamic Assist Weight Bearing Gait Analysis Assessment Problems Plan of Treatment Decline in Bed Mobility Bed Mobility Training Decline in Transfers Transfer Training Decline in Gait Progressive Gait/Stairs Training Safety Awareness Deficits Instructions on Safety Balance Deficits Balance Training ROM/Strength Deficits Therapeutic Exercises (specify) Other (specify) Patient/Caregiver/Staff Teaching Program Other (specify) Short Term Goals Long Term Goals Improve Bed Mobility to: Improve Bed Mobility to: Improve Transfers to: Improve Transfers to: Improve Gait/Stairs Mgt. to: Improve Gait/Stairs Mgt. to: Improve Safety Awareness to: Improve Safety Awareness to: Improve ROM/Strength to: Improve ROM/Strength to: Others (specify) Other (specify) Initiate Patient/Caregiver/Staff Teaching Program Independent in Home Exercise Program; Good Return Demonstration of All Instructions by Staff/Caregiver Patient's Goals Rehab Potential Tentative Discharge Plans: Home Rehab Other Frequency/Duration of Treatment Comments CLINICAL TESTS: ■Angiogram■Arthroscopy■ Biopsy ■ Blood tests ■ Bone scan■ Bronchoscopy ■ CT scan■ Doppler ultrasound ■ Echocardiogram ■ EEG (electroencephalogram)■ EKG (electrocardiogram)■ EMG (electromyogram) ■Mammogram n ■ MRI■ Myelogram■ NCV (nerve conduction velocity) ■ Pap smear ■ Pulmonary function test■ Spinal tap■ Stool tests■ Stress test (eg, treadmill, bicycle)■ Urine tests ■ X-rays■ Other:_________ Registered Physical Therapist Date Physician Approval Date Date of Referral Date of Onset Treatment Diagnosis Physical Therapy Orders History of Present Illness Past Medical History Heart problem-B.P-Chest problem-Stroke-Diabetes-Thyroid problem-Infectious disease- Kidney problems- Skin diseases-GIT-UTI-Others: Precautions Prior Functional Level Present Functional Level Psychosocial History Allergies Medications Range of Motion/Strength Orientation Responsiveness ROM/Strength ROM Strength Name Place Time Agitation Language Barrier Specify: Alert Lethargic Responds to Verbal Cue Painful Stimuli Non-Responsive Left Right Left Right Upper Extremities Prior Ambulation Community Household Assist Device Non-Ambulatory Follows Commands Confused at Times Home Environment Alone With Help Board and Care Convalescent/SN Stairs Safety Awareness Poor Fair Good Needs Verbal/Tactile Cues Lower Extremities Sensation Pain Status Trunk Strength/ROM Psychosocial Tone Coordination Barriers in Learning Endurance Comments PATIENT IDENTIFICATION