Physical Therapy Initial Evaluation Basics

The physical therapy initial evaluation (I.E.) is a documentation employed by physical therapists (PT) during the first encounter with a patient or client. It is sometimes called "initial examination" or "initial examination/evaluation." This physical therapy documentation is usually completed in one visit. Usually, evaluation takes about 30 minutes.

Included in the PT initial evaluation or examination are the following:

Examination:

This includes information obtained from history, review of systems, PT diagnostic tests and measurements.

Diagnosis

Here, the level of impairment, activity or mobility and any participation restriction is indicated as determined by the physical therapist.

Prognosis

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.


Related Books from Amazon.com (Affiliate Links)



More books on our PT Notes Associates Store


Disclosure: Just to let you know that the Amazon.com products above are affiliate links. We may get a small commission if you decide to buy from them through the affiliate links provided here. Thank you ver much.
Suggested Readings:

View More Topics About:
Conditions / Injuries | Physical Therapy | Health and Wellness

Reference:
American Physical Therapy Association (APTA). Guidelines: Physical Therapy Documentation of Patient/Client Management, available at http://www.apta.org. Accessed on June 30, 2010.