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Run: Therapy Reassessment and Functional Progress Documentation

Use this therapy reassessment template to document PT, OT, or SLP functional progress, goal status, safety concerns, and plan-of-care updates in one structur...

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Reassessment Details

Identify the therapy discipline completing the reassessment.
Document the date and time the reassessment was completed.
Select the reason(s) the reassessment was completed.
Confirm the current plan of care or referral information was reviewed before documenting findings.
Confirm current precautions, weight-bearing status, swallowing precautions, cognitive precautions, or other restrictions were reviewed.

Objective Functional Status

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

Progress Toward Goals

Summarize the change from baseline or prior reassessment using measurable terms.
Select the status that best matches the patient's active goals.
Select factors affecting progress toward goals.
Confirm whether current interventions remain appropriate based on reassessment findings.

Plan of Care Review

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

Safety, Risk, and Closeout

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

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