Is Gait Evaluation Part of Physical Therapy Review of Systems

Physical therapy documentation is an of import tool for recording therapy treatments and tracking a patient'due south progress. It can also be the cause of major headaches, rushed lunch hours, and excessive typing throughout the solar day.

Students and therapists alike have experienced difficulty locating helpful physical therapy documentation examples. I know because I, too, looked in vain for defensible documentation examples online.

Fast forward six years, and I've written thousands of physical therapy soap notes and helped hundreds of therapists with documentation examples and strategies on this web log.

Physical Therapy Documentation Examples

You may not have the fourth dimension to read dozens of documentation examples, so I have included below an instance of 4 types of notes usually used in concrete therapy.

These examples will give yous an idea of how you might perform a patient's documentation. Although they are written for a sample patient in an outpatient setting, y'all can utilise similar wording for the subjective, objective, and  cess goals in other settings (such every bit neuro, home wellness, skilled nursing, or acute rehab).

You can download these examples in PDF format here (click on image).

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Physical Therapy Evaluation Example

Evaluation Appointment: 01/06/2016

Handling Fourth dimension: 09:00 to 10:00

Patient Proper noun: Henry Smith

DOB: 3/22/1957

Physician: Dr. James Anderson

Medical Diagnosis: M17.12 Left genu OA due south/p TKA 12/28/15

PT treatment diagnosis: R26.nine Unspecified abnormalities of gait and mobility

Subjective

The patient is a 59-year-quondam male person who presents with left knee pain s/p TKA performed on 12/28/15. The patient reports having articulatio genus pain for years earlier he consulted with an ortho surgeon in August of 2015. An X-ray revealed severe arthritis and the patient elected to undergo total human knee replacement in Dec of 2015. The patient reports the surgery was performed with no issues. He was released home afterwards a one-night stay at the hospital. The patient lives with family who are able to help driving him to appointments until cleared by a doctor to drive. The patient'southward goals are to return to work as a supervisor at the local auto manufacturer, and to "walk without a walker or cane as soon as possible."

Past Medical History: High claret force per unit area

Previous PT: Yes, habitation health 4 days later surgery

Meds: Norco, tramadol, aspirin, lisinopril

Social History: Patient is married and lives in a ii-story dwelling with 4 steps to enter and 13 stairs to the basement and upstairs. Chief sleeping room/bathroom is on the master floor.

CC: Increased pain and stiffness in left knee prevents him from sleeping well at night and limits his ability to walk or stand for more than than 10 minutes.

Precautions: WBAT with FWW, progressing to cane as tolerated

Barriers to Learning: none

Home Barriers: 4 steps to enter dwelling

Prior Functional Level: Patient was contained in all areas. Patient is active in his piece of work as a flooring managing director at a local car manufacturer and could stand 8 to 10 hours a day, navigating stairs throughout the facility.

Objective

Cognition: AOx3

Vital Signs: BP 122/88, Hr 76, RR: xvi

Posture: Patient stands with forward flexed torso position using walker and demonstrates a favoring of the left knee in keeping information technology flexed.

Hurting Scale / location / behavior: Patient presents with pain along the left joint line lateral to the left patella. Patient denies tenderness behind the knee and along the incision. Pain increases with knee flexion, described equally "tightness" due to increased swelling. Patient rates pain at 4/10 at present, three/ten at all-time and 6/ten at worst. Patient reports decreased sensation along the incision line; awareness is intact otherwise.

Integumentary: Surgical incision noted along midline of left human knee. Steri strips are nowadays along a 20 cm incision. Skin appears dark pink, dry and well healing. No open up areas noted. Balmy to moderate edema noted at knee with pitting noted as 1+ at tibia. No signs of infection noted.

Lower Extremity Functional Event Score: 55% inability score

ROM / Force

* = pain	MMT R	MMT L	A/PROM (R)	A/PROM (50)
Articulatio genus Flexion	5/5	4/5	125/125	75 / 80 *
Human knee Extension	5/5	3+/5	0 / 0	-5 / – three *
Hip Flexion	v/v	4/5	120	120
Hip Extension	v/v	four/v	10	10
Hip Abduction	five/v	4/five	WNL	WNL
Talocrural joint Dorsifl.	5/5	5/five	WNL	WNL
Ankle Plantar.	5/five	4/five	WNL	WNL

Gait: Patient ambulates on level surfaces with FWW. He demonstrates gait deviations that include the post-obit: increased lateral body lean to the left with stance phase, decreased push off bilaterally, poor knee flexion with swing, decreased hip extension with push off and impaired ability to plow corners due to unsteadiness attributed to unnatural employ of walker. Advised patient on safe use of walker to encourage proximity to device.

Balance: Rhomberg stance: positive; Single-leg stance: unable on Left, for up to 3 seconds on Right. Tandem stance: requires UE support with balance loss upon perturbation.

Reflexes: DTR intact at ankle; not tested at knee due to incision at knee joint.

Extensibility: Tightness noted in the following muscle groups: bilateral hamstring, quadriceps, and gastroc/soleus.

Special Tests:  PDVT Screen: negative.

Treatment Provided: Total knee protocol to include instruction of HEP and performance of the following exercises: ankle pumps x 20, quad sets x 15, SLR ten 10, sidelying SLR 10 x, glute squeezes x xx, mini squats 10 ten, heel slides x 15. Cold pack 10 10 minutes in supine post-obit ther ex.

Physical Therapy Cess

Trouble Summary: Increased pain at left knee, decreased ROM of left knee, decreased strength of L LE, balance deficits in standing, difficulty with weight bearing activities, contradistinct posture, lack of habitation exercise programme, impaired gait course and use of assistive device.

Assessment Argument: Patient presents with signs and symptoms consequent with diagnosis of Fifty knee joint OA, s/p i week post operative L TKA. Rehab potential is excellent. Primal impairments include: decreased ROM and strength of the left lower extremity, poor balance and compensatory gait patterning, increased swelling, and hurting with functional activities such as squatting, walking, and stairs. A skilled PT is required to address these key impairments and to provide and progress with an appropriate home exercise plan. This evaluation is of moderate complication due to the irresolute nature of the patient's presentation as well as the comorbidities and medical factors included in this evaluation.

Goals

Short Term Goals

Within ii weeks, the patient will achieve xc˚ knee flexion consistently in order to progress with functional activities such every bit rise from a chair with equal weight bearing.

Inside 2 weeks, the patient will demonstrate improved quad strength and motor control as noted past ability to perform SLR without lag in gild to progress into advanced ther ex.

Within ii weeks, the patient will report a xx% reduction in knee pain at dark in guild to facilitate their ability to fall asleep.

Long Term Goals

Within 4 weeks, the patient volition demonstrate contained ambulation on level surfaces without a straight cane in guild to safely navigate the community without gait compensation.

Within 5 weeks, the patient will demonstrate an increase in quadriceps strength by i MMT form to ascend and descend stairs without the human knee buckling.

Within vi weeks, the patient volition demonstrate increased knee flexion AROM to 120 in order to improve the patient's ability to descend 2 flights of stairs at work.

Inside 6 weeks, the patient will report the ability to walk for 45 minutes without knee hurting in gild to perform piece of work tasks such as navigating the found facility.

Plan

Patient will be seen by a PT and/or PTA 2x per calendar week for 6 weeks nether the diagnosis of Left knee joint OA south/p 50 TKA and will be reassessed every 7-ten visits for progress.

Handling to Include: AROM/AAROM/PROM, balance and proprioception training, strengthening exercises, HEP, mobilization, posture/torso mechanic training, neuromuscular re-education, and ice pack to LLE.

Certification period: 1/6/xvi – 2/24/16

The patient has been educated in the evaluation findings, prognosis, and plan of care, and is in agreement and willing to participate in therapy.

Cheers for this referral and please telephone call thirty-xxx-xxxx with whatsoever questions or concerns.

Concrete Therapist: _______________________  Appointment:_________ Time: _________

Physician Signature: ______________________  Date: ________ Time: _________

Billing

CPT Code	Procedure	Unit   / Time
97162	PT Evaluation (Moderate)	1 / 25 minutes
97110	Therapeutic Practise	ii / 25 minutes
97010	Cold Pack (untimed)	1 / x minutes
	Total Treatment Time	lx minutes
	Full Timed Minutes	50 minutes

Physical Therapy Daily Note Example

Treatment Engagement: 01/08/2016

Treatment Time: ten:00 to 10:50

Patient Name: Henry Smith

DOB: 3/22/1957

Physician: Dr. James Anderson

Medical Diagnosis: M17.12 Left knee OA s/p TKA 12/28/xv

PT handling diagnosis: R26.9 Unspecified abnormalities of gait and mobility

Subjective

Patient stated "I am meliorate able to sleep at night with less throbbing in my knee. Today my pain level is 3/10."

Objective

Patient used FWW to ambulate into clinic with equal footstep length noted.

xx minutes Therapeutic Exercise (97110): Supine exercises included: active quad sets 10 fifteen, SLR x 15, Hamstring curl x x with ankle dorsiflexion x 3 each rep, SAQ with bolster x xv. PROM flexion to 95 degrees. Standing: mini squats x 10, hip abduction x 10 bilaterally, hamstring curls x 15 bilaterally, step upward to 3" step 10 10 alternating LE.

10 minutes Neuromuscular Re-pedagogy (97112): Weight shifting on balance pad 3×20 seconds, Rhomberg stance on pad 3×xx seconds with one UE back up, semi tandem stance with perturbations from therapist 2×1 min., rocker board for proprioceptive grooming x three min.

10 minutes Manual Therapy (97140): Seated tibiofemoral distraction grade 2 mobilization for pain relief, supine patellar mobilizations in superior/inferior direction: grade 2 x 4 minutes, mobilization with movement of patella with SAQ 10 3 minutes.

10 minutes Common cold Pack (97010): Left knee patient in supine with human knee supported by eternalize for comfort following exercises and treatment. Instructed patient to continue using ice intermittently at home with elevation throughout the day to minimize swelling.

Cess

The patient demonstrates lack of quad muscle recruitment during knee extension. Instructed patient in co-contraction of quads to ameliorate motor recruitment in lodge to achieve greater genu extension. Poor rest on an uneven surface noted during treatment. Continued use of FWW recommended.

Plan

Progress patient with strengthening exercises to increment quad activation and trial straight cane at parallel bars.

Therapist Signature: _________________  Date: _____________ Fourth dimension: __________

CPT Code	Procedure	Unit   / Time
97110	Therapeutic Exercise	1 / xx minutes
97112	Neuromuscular Re-ed	one / ten minutes
97140	Transmission Therapy	one / ten minutes
97010	Cold Pack	1 / 10 minutes
	Full Handling Time	fifty minutes
	Total Timed Minutes	40 minutes

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Progress Note Case

Treatment Date: 01/27/2016

Treatment Fourth dimension: 10:00 to 11:00

Time Catamenia: 01/06/16 to 1/27/16

Commencement of Care: 1/vi/16

Patient Name: Henry Smith

DOB: 3/22/1957

Doctor: Dr. James Anderson

Medical Diagnosis: M17.12 Left knee OA s/p TKA 12/28/15

PT treatment diagnosis: R26.nine Unspecified abnormalities of gait and mobility

Subjective

Hurting/Location: 2/10; Patient states, "My knee pain has decreased significantly, allowing me to slumber through the nighttime and to sit and stand from chairs much more hands. I can walk for well-nigh 20 minutes with the cane before I need to sit down to rest."

Attendance: Number of Treatments: 7; Cancellations: 0; No Shows: 0

Handling Included: Ther ex, neuromuscular re-ed, manual therapy, cold pack, HEP

Objective Findings

SLR lag: ane degree, Rhomberg test: negative; sensation: intact; incision: closed, clean, and healing well. Patient uses a straight pikestaff for airing.

Treatment Provided

(Examples for handling provided would follow a similar format equally noted to a higher place in the Daily Note Case. You may also certificate treatment provided in a menses canvas. To shorten this example, the treatment has been omitted only would follow a similar format as the treatment listed in the Sample Daily Annotation.)

* = pain	MMT R	MMT L	A/PROM (R)	A/PROM (L)
Knee Flexion	5/5	4+/5	125/125	100 / 110
Knee Extension	5/5	4/five	0 / 0	-2 / – 2 *
Hip Flexion	v/5	4+/v	120	120
Hip Extension	5/5	4+/5	x	ten
Hip Abduction	v/5	iv+/v	WNL	WNL
Ankle Dorsifl.	5/five	v/v	WNL	WNL
Talocrural joint Plantar.	v/5	four+/5	WNL	WNL

Assessment & Goal Status

The patient is progressing well towards goals established at evaluation, achieving 100% of brusque-term goals. Long-term goals will be addressed with farther treatment. Patient lacks full strength to arise full flight of stairs reciprocally and demonstrates dumb residual on dynamic surfaces.

Plan

☐ Discharge from PT    x Continue PT ii 10 per week for 3 weeks

To focus on quad strengthening, stair navigation, rest training, and gait grooming.

Therapist Signature:  ______________ Date: ____________  Time: _________

Physician Signature: ______________      Date: ____________  Time: _________

Please sign and fax to: ____________

CPT Code	Process	Unit of measurement   / Time
97110	Therapeutic Do	1 / 20 minutes
97112	Neuromuscular Re-ed	ane / 20 minutes
97140	Manual Therapy	1 / 10 minutes
97010	Cold Pack	1 / ten minutes
	Total Treatment Time	60 minutes
	Total Timed Minutes	l minutes

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Discharge Note Case

Treatment Date: 02/17/2016

Treatment Time: ten:00 to 10:fifty

Fourth dimension Menstruum: 01/27/16 to 02/17/16

Start of Intendance: 1/six/16

Patient Name: Henry Smith

DOB: three/22/1957

Physician: Dr. James Anderson

Medical Diagnosis: M17.12 Left knee OA southward/p TKA 12/28/15

PT treatment diagnosis: R26.9 Unspecified abnormalities of gait and mobility

Subjective

Pain/Location: 0/10; Patient states, "I no longer need to utilize the pikestaff and have been able to navigate up and down my steps eight times a day. My LE swells when I stand more than iii hours at a fourth dimension, simply resting for 20 minutes allows me to stand throughout the twenty-four hour period. I program to render to work March seventh following my visit with the surgeon on 3/4/xvi."

Attendance:  Number of Treatments: 13; Cancellations: 0; No Shows: 0

Handling Included: Ther ex, neuromuscular re-ed, manual therapy, cold pack, HEP

Objective Findings

Rhomberg test: negative; awareness: intact; incision: airtight, clean, and healing well. LEFS: 10% perceived impairment. No assistive device used.

Treatment Provided

(Examples for treatment provided would follow a similar format as noted above in the Daily Note Instance. You may also document treatment provided in a flow sheet. To shorten this instance, the treatment has been omitted simply would follow a like format as the treatment listed in the Sample Daily Note.)

* = pain	MMT R	MMT L	A/PROM (R)	A/PROM (L)
Knee Flexion	5/five	5/5	125/125	120 / 120
Knee Extension	five/five	5/5	0 / 0	0 / 0
Hip Flexion	v/v	five/5	120	120
Hip Extension	5/v	five/5	x	ten
Hip Abduction	5/5	5/5	WNL	WNL
Ankle Dorsifl.	5/5	5/five	WNL	WNL
Talocrural joint Plantar.	five/v	5/5	WNL	WNL

Assessment & Goal Status

The patient has accomplished 100% of short-term and long-term goals. He demonstrates overall improved forcefulness and stability with functional activities and with gait class. Patient is independent with advanced HEP and is amusing to discharge with all goals met.

Plan

x Discharge from PT with all goals met.

Therapist Signature:  _____________ Date: ____________  Time: _________

Doc Signature: ______________      Date: ____________  Fourth dimension: _________

CPT Lawmaking	Procedure	Unit   / Fourth dimension
97110	Therapeutic Do	1 / 15 minutes
97112	Neuromuscular Re-ed	1 / xv minutes
97530	Therapeutic Activity	i / 20 minutes
	Full Treatment Time	l minutes
	Total Timed Minutes	50 minutes

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Physical Therapy Documentation Phrases

Make it the habit of starting your sentences with action words that describe the patient's ability to perform functional tasks.

Here are a few keywords to consider:

"The patient…

• performs, demonstrates, reaches, achieves/does not attain, lacks, displays

"A functional movement…

• overhead lifting, reaching, pulling, gripping, squatting, lateral shifting, single-leg stance

"With an identified arrears or quality of operation…

• poorly, with decreased stability, with insufficient muscle recruitment, with unsafe control,

"Causing….

• poor foot clearance, improper hip alignment, impaired posture, increased stress, further irritation.

"Reason for Therapy to go along…." or "Central impairments to be addressed with further therapy in society to …

• to progress with stability preparation, to subtract the risk of falling, to safely manage lifting # items at home, to independently don/doff clothing, to perform head checks in vehicle safely, etc."

It's not enough to simply say, "The patient performed the exercises with good form."

That doesn't tell us annihilation, and it neglects to mention any cueing you provided. If you didn't provide any cueing, recommendation, or therapeutic insight or intervention, what did you exercise??

Physical Therapy Assessment Documentation

Most of the difficulty in writing defensible documentation lies in the assessment section.

By the fourth dimension yous get to this section, you lot might feel as if yous've used all your mental free energy typing the preceding subjective and objective sections!

With my 60+ examples of assessment phrases in existent-life scenarios, yous'll have access to a comprehensive resource that will improve the efficiency and quality of your writing. These Therapy Documentation Templates will help you effortlessly write physical therapy assessment phrases that are as skilled equally the treatments you provide in the clinic.

Y'all know y'all are providing your patients skilled treatment.

Make sure your documentation shows information technology – but in less fourth dimension and with improve clarity!

Download the Therapy Documentation Templates to salve fourth dimension in the clinic.

Considering Physical Therapists deserve to go home to family, not paperwork.

Save xxx-hr a day with the Therapy Documentation Templates.

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Source: https://www.ptprogress.com/physical-therapy-documentation-examples/