Home Exercise Program Prescription and Delivery

Document prescribed home exercises, dosage, patient education, demonstration, and understanding at the time of delivery.

Visit and Patient Context

• Patient Identifier
  Enter the patient ID or chart number used in your system. Do not enter a full SSN or other unnecessary PII.
• Visit Date
• Discipline
• How was the home exercise program delivered?
• If other, describe the delivery method

Prescribed Exercises

• Prescribed Exercises
• Intensity or effort guidance
  Enter any pain-free range, resistance, pace, or effort guidance provided.
• Precautions or stop criteria
  Document any symptoms, movements, or conditions that should stop the exercise and prompt follow-up.

Patient Education and Understanding

• Education topics covered
• Did the patient demonstrate the exercises?
• Demonstration quality
• Patient understanding confirmed
• Education notes
  Document any teach-back, questions answered, or follow-up instructions provided. Include only minimum necessary details.

Follow-Up and Attestation

• Follow-up plan
  Enter the next visit plan, reassessment timing, or instructions for contacting the clinic.
• Patient acknowledgment of receipt
• Clinician Name
• Clinician Signature