PT Visit Note (Jennifer D. Patient)

PT Visit Note
Patient Name

First NameLast Name
Date of Visit

MonthDayYear
Date
Time In:*
Time Out:*
Agency*
Agency Name
Homebound Status:

Requires assist with ADL’sMedically contraindicatedUnable to ambulate functional distanceRequires assist with ambulationAltered MentationRequires assist with transfersBedboundPain above 4/10SOB with minimal activityPsychiatric DisorderOther
Pain

No PainIntermittent PainConsistent Pain
Pain Level Pain Level /10
Pain Location Precipitating factors
Vital Signs
BP
Temp
Pulse
Resp
Sp02
Edema?

YesNo
Edema Level (1+- 4+)
Edema Location
Subjective
Interventions

Therapeutic ExerciseBalance/CoordinationTransfer TrainingGaitHome Exercise ProgramOther (Please describe below)
Therapeutic Exercise
Sets
Reps
Resistance
Exercises performed
Ther Ex Skilled Teaching and Patient Response to Teaching
Balance/Coordination
TUG:
Device
Balance Training
Balance Training Skilled Teaching and Patient Response to Teaching
Transfers Practiced
Transfer Training Skilled Teaching and Patient Response
Gait
Device Required:
Skilled Assistance Required
Patient Response
Gait Skilled Teaching Provided and Patient Response to Skilled Teaching
Gait Deviations

Decreased Weight Shift LEFTDecreased Weight Shift RIGHTDecreased Step Length LEFTDecreased Step Length RIGHTDecreased Toe Clearance LEFTDecreased Toe Clearance RIGHTAntalgicWide BOSTrendelenburgCircumductionSteppageOther
HEP

Established/Revised HEPCopy Left for patient
Comments
Other Interventions
Goals
Goal 1
Progress Towards Goal %
Status/Specify
Goal 2
Progress Towards Goal %
Status/Specify
Goal 3
Progress Towards Goal %
Status/Specify
Goal 4
Progress Towards Goal %
Status/Specify
Goal 5
Progress Towards Goal %
Status/Specify
Goal 6
Progress Towards Goal %
Status/Specify
Comments
Plan for Next Visit
Participation and Follow Through is

AdequateInadequateN/AOther
Supervisory Visit

(If Applicable)
Was this a Supervisory Visit?

YesNo
Therapy/Aide Present this visit?

YesNo
Following Plan of Care?

YesNo
Courteous and Polite?

YesNo
Reports Changes in Status?

YesNo
Patient Satisfied with Care

YesNo
Changes Made to POC?

YesNo
Communication
Conferenced With
Date
Regarding
Discharge Discussed with:

Patient/FamilyCase ManagerPhysicianOther
Client Name

First NameLast Name
Date

MonthDayYear
Date
Client Signature

Clear
Therapist Name
Therapist Name*

First NameLast Name
Date

MonthDayYear
Date
Therapist Signature

Clear
Co-Signature (if applicable)

Clear
Therapist Email*
example@example.com
Are you sure you want to submit this form?*

Yes
Should be Empty:

PT Visit Note

Goals

Supervisory Visit

Communication