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Beginning Time
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Ending Time
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Returned to PT after Discharge
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Pain (since last visit)
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Pain Rating
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Functional Movement (since last visit)
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Ability to Ambulate (since last visit)
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Range of Motion (since last visit)
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Strength (since last visit)
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ADL Ability (since eval)
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Self-Summary (since eval)
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HEP Compliance
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Additionally, patient reports
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PT Re-eval/Affected Areas
• • •
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AROM Measurements (give area, values)
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MMT Measurements (give area and values)
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Treatment Affected by Other Factors
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Factors Affecting Treatment (phrase)
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Adverse Reactions to Treatment
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Adverse Reactions List
• • •
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Adverse Reactions not listed
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Goals Met
• • •
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Additional information includes
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Problem List
• • •
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Changes in Plan of Care
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Physical Therapy Assessment
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New STG 1 Pain
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New STG 2 AROM
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New STG 3 MMT
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New STG 4 ADL Function
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New STG 5 HEP
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New STG 6 RTW
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New STG 7 Miscellaneous
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New LTG 1 Pain
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New LTG 2 AROM
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New LTG 3 MMT
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New LTG 4 ADL Function
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New LTG 5 HEP
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New LTG 6 RTW
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New LTG 7 Miscellaneous
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Mobility G-code
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Mobility G-code Modifier
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Changing and Maintaining Body Position G-code
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Changing and maintaining modifier
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Carrying, Moving & Handling Objects G-code
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Carrying G Code modifier
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Self Care G-code
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Self-care modifier
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Interventions This Visit
• • •
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Physical Therapy Re-evaluation
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Therapeutic Exercise
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Cervical AROM Exercises
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Shoulder AROM Exercises
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Elbow AROM Exercises
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Wrist AROM Exercises
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Hand AROM Exercises
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Lumbar AROM Exercises
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Hip AROM Exercises
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Knee AROM Exercises
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Ankle AROM Exercises
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Core Muscle Exercises
• • •
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Postural Exercises
• • •
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Additional info for Ther Ex
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Manual Therapy locations
• • •
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Manual Therapy Choices
• • •
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Additional info for Manual Therapy
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Ultrasound
• • •
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Additional info for Ultrasound
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Physical Therapy Assessment Problems
• • •
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Progress??
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Additional info for Assessment/Progress
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Goals Met
• • •
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Changes in HEP
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Return Appointment
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Plan of Care
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Medical Necessity
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Reasons for Discharge
• • •
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Summary of Care
• • •
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Discharge Plan
• • •
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Physical Therapy Status
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Static/Stable
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Additional information includes
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