Therapy Reassessment and Functional Progress Documentation

Inspection template for documenting PT, OT, and SLP reassessments, objective functional progress, goal status, and any need to update the plan of care.

Reassessment Details

• Discipline documented
  Identify the therapy discipline completing the reassessment.
• Reassessment date and time recorded
  Document the date and time the reassessment was completed.
• Reason for reassessment documented
  Select the reason(s) the reassessment was completed.
• Referring provider / plan of care reviewed
  Confirm the current plan of care or referral information was reviewed before documenting findings.
• Relevant precautions or restrictions reviewed
  Confirm current precautions, weight-bearing status, swallowing precautions, cognitive precautions, or other restrictions were reviewed.

Objective Functional Status

• Current functional level documented
  Rate the patient's current overall functional status compared with the prior assessment.
• Mobility / transfer status documented
  Describe current bed mobility, transfers, gait, balance, or wheelchair mobility status using objective terms.
• ADL / IADL performance documented
  Describe current self-care, dressing, bathing, toileting, meal prep, or home management performance as applicable.
• Communication / swallowing / cognition status documented
  For SLP or when relevant, document speech intelligibility, language, cognition, voice, or swallowing status using objective observations.
• Objective measures captured
  Record measurable findings such as range of motion, strength, gait distance, assist level, standardized test score, cueing level, or swallow tolerance.

Progress Toward Goals

• Baseline compared to current status
  Summarize the change from baseline or prior reassessment using measurable terms.
• Progress toward each active goal assessed
  Select the status that best matches the patient's active goals.
• Barriers to progress identified
  Select factors affecting progress toward goals.
• Therapy interventions remain appropriate
  Confirm whether current interventions remain appropriate based on reassessment findings.

Plan of Care Review

• Goals updated or continued as indicated
  Indicate whether goals were continued, modified, added, or discontinued based on current findings.
• Frequency / duration reviewed
  Confirm therapy frequency, duration, or visit count was reviewed and adjusted if needed.
• Discharge readiness assessed
  Document whether the patient is approaching discharge, requires continued skilled therapy, or needs a higher level of care.
• Recommendations documented
  Enter recommendations for continued treatment, home exercise or home program updates, caregiver training, referrals, or equipment needs.

Safety, Risk, and Closeout

• Safety concerns identified
  Indicate whether any safety concerns were identified during reassessment, such as falls risk, aspiration risk, skin integrity concerns, or unsafe mobility.
• Corrective action or escalation documented
  Document any escalation to the provider, care team, supervisor, or caregiver, and any immediate corrective action taken.
• Inspector signature completed
  Therapist signature confirming the reassessment and documentation are complete.