Included in the PT initial evaluation or examination are the following:
This includes information obtained from history, review of systems, PT diagnostic tests and measurements.
Here, the level of impairment, activity or mobility and any participation restriction is indicated as determined by the physical therapist.
This part may include documentation of the predicted level of improvement (goals) that may be attained through the proposed treatment interventions. It also includes the duration or amount of time required to reach those goals. Prognosis documentation is usually included in the plan of care and is not necessarily a separate document. (See plan of care below)
Plan of Care
The plan of care of the initial evaluation or examination is usually stated in general terms. It includes the goals, which are stated in measurable terms; planned treatment interventions; proposed frequency and duration of therapy required to attain the goals; and discharge plans as determined by the therapist.
The plan of care in the I.E. is based on the specific problems of your client. Often, it is related to the results of the examination.
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American Physical Therapy Association (APTA). Guidelines: Physical Therapy Documentation of Patient/Client Management, available at http://www.apta.org. Accessed on June 30, 2010.