Objective, Assessment, Plan (Therapist Use)

Patient Initials
E.g. Nina Evangelista: NE
Date

MonthDayYear
Date
Therapist
SUBJECTIVE:
Narrative
Symptom Trending
How are your symptoms since previous session? "How are you feeling today?"
Symptom/Pain Level
e.g. Pain, Weakness, Unsteadiness, Movement difficulty
Patient Motivation At Arrival
Did you do your homework?
Homework can be a self treatment technique/HEP taught by the therapist from previous session.
Do you know of any limitation or barriers that prevent you from achieving your physical therapy goals?
Limiting Factors (e.g. schedule conflicts, transportation issues, work, highly stressed at this time)

OBJECTIVE: What is Patient's Goal?
Refer to 1st Visit Summary on patient's goal. Enter it here
Primary Functional Loss
May refer to 1st Visit Summary on Primary Functional Loss. Enter it here
Objective data 1
Measurable Change 1 (Tests and Measures) ROM, Palpation, MMT, Special Tests, Vitals
Objective data 2
Measurable Change 2 (Tests and Measures) ROM, Palpation, MMT, Special Tests

ASSESSMENT: Patient will cont to benefit from PT management in order to:
Note: 1. Changes in performance (Progression/Regression) 2. Toleration of tx 3. Response to Tx
Limiting Factors To Success (If any)
Physical Therapy barriers or concerns during the rehabilitation phase
HEP Update/Supplies or Equipment Recommendation
Tech can revise the HEP in WebPT to send to patient

PLAN:
Education, Plan for communication with healthcare team or caregivers or supervising therapist, Any Plan for Next Visit

BILLING 97110 (THEREX)
Enter rationale please, minutes, E.g.See exercise log for strengthening and flexibility (1 unit/8 min)
BILLING 97112 (NMED)
Enter rationale please, E.g.See exercise log for core stabilization, balance and proprioception to L ankle (2 units/23 minutes)
BILLING 97140 (MANUAL THERAPY)
Please enter manual intervention/s done, units/minutes, E.g. MFR to B gluteus medius, Maximus, QL and TPR to R QL (2 units/25 min)
BILLING 97014 (ESTIM) or G0283 for MEDICARE
Enter body part, Premod VS IFC and rationale please, minutes E.g. HMP with Premod to B UT (15 min)
BILLING 97535 SELF CARE
Please enter details: HEP, Education, Ergonomics, Self treatment techniques
BILLING Other (97116 Gait, 97035 US, etc)
Please enter details.
Therapist:
Supervising Therapist:
Email report to
Provider Signature
Patient/Caregiver Signature (FOR HOME VISITS ONLY)

p. 443.979.7171

AAA Physical Therapy, LLC
admin@AAAPhysicalTherapy.com
8975 Guilford Rd Ste 170
Columbia, MD 21046

f.667.200.5908