Objective, Assessment, Plan (Therapist Use)

Patient Initials*
E.g. Nina Evangelista: NE
Date*

MonthDayYear
Date
Therapist*

Nina Evangelista, PTOlive Toledo, PTJoanne Colburn, PTAimee Schuh, PTJoane Luna PTAGeraldine Soliven, PT
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*

Clear
Patient/Caregiver Signature (FOR HOME VISITS ONLY)*

Clear

p. 443.979.7171

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

f. 667.200.5908

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