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Run: Therapy Evaluation and Plan of Care

Therapy Evaluation and Plan of Care template for documenting baseline function, clinical findings, goals, and the recommended therapy schedule in one signed ...

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Patient and Referral Information

Patient Identifier (required)

Use the facility medical record number or other internal identifier. Do not enter SSN.

Patient Name (required)

Date of Evaluation (required)

Referring Provider

Therapy Discipline (required)

Care Setting (required)

If other, specify care setting

Reason for Referral and Prior Level of Function

Reason for Referral (required)

Prior Level of Function (required)

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 (required)

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 (required)

Long-Term Goals

Treatment Frequency (required)

Example: 5x/week, 3x/week, or 2-3x/week.

Planned Duration (Weeks) (required)

Planned Interventions

If other, specify planned interventions

Discharge Planning Considerations

Consent, Attestation, and Submission

PII and Record Use Disclosure (required)

Yes No N/A

Consent Documented in Record

Yes No N/A

Clinician Name (required)

Clinician Credentials (required)

Clinician Signature (required)

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Email (required)

Your name (optional)

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