Therapy Evaluation and Plan of Care

Initial skilled therapy evaluation form for documenting prior level of function, current status, clinical findings, goals, and the recommended frequency and duration of therapy services.

Patient and Referral Information

• Patient Identifier
  Use the facility medical record number or other internal identifier. Do not enter SSN.
• Patient Name
• Date of Evaluation
• Referring Provider
• Therapy Discipline
• Care Setting
• If other, specify care setting

Reason for Referral and Prior Level of Function

• Reason for Referral
• Prior Level of Function
  Describe mobility, self-care, communication, swallowing, cognition, or other relevant baseline abilities before the current episode.
• Living Situation Before Current Episode
• Assistive Devices Used at Baseline
• If other, specify assistive device

Current Functional Status and Clinical Findings

• Current Functional Status Summary
• Mobility Status
• Activities of Daily Living Status
• Communication or Swallowing Status
• Pain Rating
• Precautions and Safety Considerations
• If other, specify precautions

Discipline-Specific Evaluation

• Gait and Transfer Findings
• Strength, Balance, and Endurance Findings
• ADL and IADL Findings
• Cognition, Perception, and Safety Findings
• Speech, Language, and Cognitive-Communication Findings
• Swallowing and Diet Tolerance Findings

Goals and Plan of Care

• Short-Term Goals
• Long-Term Goals
• Treatment Frequency
  Example: 5x/week, 3x/week, or 2-3x/week.
• Planned Duration (Weeks)
• Planned Interventions
• If other, specify planned interventions
• Discharge Planning Considerations

Consent, Attestation, and Submission

• PII and Record Use Disclosure
• Consent Documented in Record
• Clinician Name
• Clinician Credentials
• Clinician Signature