Physical Therapist Initial

History of Present Illness [Report in chronological order describing the patient and why they are coming to physical therapy] [Describe how the injury occurred. Report as “insidious onset” if no specific event occurred] Signs and Symptoms [Report descriptor words the patient uses to describe their pain. If they aren’t able to describe their pain, report as “pain”] Pain at present [Report patients pain at present rated from 0 to 10] [If no pain number is given, report it as mild, moderate, or severe] Aggravating and easing factors Aggs: [Report all activities that aggravate patients reported pain][Report as none if nothing makes it worse] Ease: [Report all activities that make the patients reported pain better][Report as none if nothing makes it better] Activity Limitations [List any activities the patient cannot perform due to their injury] Co-morbidities/Complexities [List any co-morbidities or other diseases the patient has here] [Report “none” if patient has no co-morbidities] Prior treatments / surgeries [List any treatments including injections, chiropractic, other PT, or surgeries for the issue they are coming to physical therapy for today] [List all providers they are seeing for this issue] [Report “None” if they haven’t received any treatments, surgeries, and aren’t seeing any other providers] Prior imaging /studies [List findings of any imaging studies they have had including but not limited to x-ray, CT scan, MRI, fluoroscopy, etc] [Report “none” if they have not had any imaging] Goals [List the patients stated goals with physical therapy] OBJECTIVE [Report all objective findings] (List it in a logical order with headers when appropriate) Assessment: [Write an assessment as a paragraph summarizing the patients history and objective measures.] [Include the likely diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] [Include why the patient would benefit from skilled physical therapy] GOALS [Write 5 functional physical therapy goals that are Specific, Measurable, Achievable, Relevant, and Time-bound that are 6 weeks or longer. List them as bullets, not numbers.] Plan: - [Investigations planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] - [Treatment planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] - [Relevant other actions such as counseling, referrals etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note.)