Physical Therapy Progress Note Template printable pdf download

Physical Therapy Progress Note Template

Home Care

Physical Therapy Progress Note

Time In: ________

Time Out: _________

Visit Date: ______

Patient Signature:___________________________

Agency:

Patient Name:

Homebound Status:

Subjective:

Objective:

□ Oriented

□ Forgetful

□ Disoriented

□ Agitated

□ Comatose

□ Depressed

□ Lethargic

Mental Status:

Therapeutic Exercise:

Balance Training:

Transfer Training:

Deviations/ Correction:

Bed Mobility Training:

Deviations/Correction:

Gait Training/Wheelchair Mobility Training

Pain:

Other:

□ Patient

□ Caregiver

□ Patient/Caregiver

□ Safety

□ Proper Positioning

Instructions:

□ Deep Breathing

□ Proper Modality Use

□ HEP

□ Postural corrections

Outcome/Progression toward goal:

Plan:

D/C plans discussed with: □ Patient

□ Caregiver

□ Physician

□ Other

Reported:

Care Coordination: □ PT

□ ST

□ HHA

□ MSW

□ OT

□ SN

□ Other

LPTA/Aide supervision (complete if applicable):

□ Introduction

□ Supervision

LPTA/Aide present □ Yes

□ No

LPTA/Aide following plan: □ Yes

□ No (explain):

HHA care plan:

□ Reviewed

□ Revised/updated:

Next supervisory visit:

Next Physical Therapy Visit:

Therapist Signature/Title:

Physical Therapy Progress Note Template

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