Documenting Skilled Care During a Physical Therapy Evaluation

During an initial evaluation it is very important you document skilled care and make sure you take notes of all your patients deficits and safety concerns.

There a few things I do during every evaluation and I have them listed below.

And for your reference I do Medicare Part B so outpatient in the home and assisted livings. So if you do home care this will be different. If you work in an outpatient clinic, however, you should include all of the below as well.

• Reason for the referral to PT. Note if it was because of one or more of these things:
  • hospitalization
  • recent fall
  • pain
  • difficulty walking
  • decrease in balance
  • functional decline
  • injury
  • surgery
• Medications
• Past Medical history
• Falls in the last year
• Hospitalizations in the last 4 months
• Precautions such as:
  • decreased awareness
  • fall risk
  • allergies
  • medical conditions
  • etc (anything to watch out for)
• Pain level
• Vitals
• About living environment (house/apartment, stairs, bathroom situation, if lives alone or with family, caregiver assistance)
• Prior level of function for every activity you might treat such as bed mobility, transfers, ambulation on level, stairs, wheelchair mobility
• Equipment the patient has
• Subjective comment from patient or caregiver
• Objective measures (I do not do all of the ones below. Just what applies to this patients situation)
  • Bed mobility
    • Activity performed such as supine to or from stand, rolling, side lying, scooting
    • Direction if necessary
    • Any equipment, railings used, head of bed elevated
    • Level of assist required (can be physical, verbal, visual, tactile)
    • Why that patient is that level of assist such as secondary to: technique, strength/ROM, aerobic capacity, safety, cognition, balance, posture, coordination, vision
  • Transfers
    • Type of transfer: squat pivot, stand pivot, sliding board, sit to or from stand, mechanical, floor to or from stand
    • Surface it was performed from
    • Any equipment needed
    • If UE's were used
    • Level of assist required (can be physical, verbal, visual, tactile)
    • Why that patient is that level of assist such as secondary to: technique, strength/ROM, aerobic capacity, safety, cognition, balance, posture, coordination, vision
  • Gait
    • Type of mobility whether it's on level surface or unlevel surface
    • The type of surface such as carpel, wood, grass, gravel, etc
    • Distance ambulated
    • Equipment used
    • Deviations present such as but not limited to: antalgic, decreased arm swing, decreased step length, decreased step height, decreased cadence, increased base of support, decreased base of support, difficulty turning, decreased heel strike, festinating, lateral trunk lean, etc
    • Level of assist required (can be physical, verbal, visual, tactile)
    • Why that patient is that level of assist such as secondary to: technique, strength/ROM, aerobic capacity, safety, cognition, balance, posture, coordination, vision
  • Stair Mobility
    • Whether it was ascending, descending or both 
    • How many stairs or was it a curb
    • Any railings
    • Any deviations such as step to pattern or sideways 
    • Level of assist required (can be physical, verbal, visual, tactile)
    • Why that patient is that level of assist such as secondary to: technique, strength/ROM, aerobic capacity, safety, cognition, balance, posture, coordination, vision
  • Wheelchair Mobility
    • What type of chair: manual, power, scooter
    • Method: using arms or legs or both
    • The distance
    • Any deviations noted
    • Any equipment such as brake extenders, cushions, anti-tippers, seat belt, etc
    • Level of assist required (can be physical, verbal, visual, tactile)
    • Why that patient is that level of assist such as secondary to: technique, strength/ROM, aerobic capacity, safety, cognition, balance, posture, coordination, vision
• Functional Outcome Measures (On evaluation I normally do)
  • 5x sit to stand
  • Timed up and go (TUG)
  • On another day a few others I may test are: Berg, gait speed, 2 or 6 minute walk test, functional reach, single leg stance, heel rise test (of course there are many more but those are the most common I do.)
• Assessment - I include why they were admitted to PT and then briefly what I found. I then explain why they are a good candidate for skilled PT and why they will benefit.
• Document their rehab potential: good, fair or other and then explain
• If it's for rehabilitation or maintenance (which is ok as long as the therapy provided is SKILLED and a caregiver CANNOT do it)
• Clinically complex situations such as: musculoskeletal issues or cognitive issues
• Complexity: low, medium, high
• Plan of care
• Frequency of treatment and for how long expected
• Diagnosis (at least 2 rehab and 1 medical)
• Treatment for that day

I really hope that was helpful!!!

If you go to the highlight on our IG you can see me do most of this evaluation with a patient (actually it's my student) but it's all there.

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