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Progress Note / Plan of Care
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Frequency and Duration of Care
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Patient to be seen
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Times per week:
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Number of weeks:
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Plan of Care: Short Term Goals
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Short term goal 1
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Short term goal 2
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Short term goal 3
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Short term goal 4
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Short term goal 5
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# of Weeks Expected to Meet Goals
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Plan of Care: Long Term Goals
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Long term goal 1
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Long term goal 2
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Long term goal 3
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Long term goal 4
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Long term goal 5
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# of Weeks Expected to Meet Goals
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Functional Deficits Treatment Plan
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Prior Functional Levels
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Complete independence in performance
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See Functional Deficits Below
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Functional Deficits includes
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Driving
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Additional comments
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Perform Meal Preparation Deficits Status
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Additional comments
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Reach into Kitchen Cabinet Deficits Status:
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Additional comments
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Lift / Carry Laundry Baskets Deficits Status:
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Additional comments
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Perform Light Household Cleaning Tasks Status:
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Additional comments
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Sleep Disturbance Deficits Status:
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Additional comments
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Forward Bend to Complete Dressing Status:
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Additional comments
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Ascend/Descend Stairs to Bedroom/Basement
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Additional comments
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Walk Deficits Status: (Add comment detail)
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Additional comments
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Complete Yard Maintenance Deficits Status:
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Additional comments
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Lift or Carry Groceries into the House Status:
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Additional comments
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Squat Deficits Status:
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Additional comments
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Change Direction without LOB Deficits Status:
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Additional comments
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Multi-Task and Maintain Balance Deficits Status:
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Additional comments
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Other Comments
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Additional comments
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Treatment will consist of:
• • •
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Plan of Care Statement
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Plan of Care Statement
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Doctor agree with Plan of Care:
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Declaration
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