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PHYSICAL THERAPY VISIT NOTE
Patient Name: _________________________________________________ Date: __ /__ /____ Time In: _____ am/pm Out: ____ am/pm
Agency Name
: __________________________________________________________________________________________________________
Patient Complaint/problems
: _____________________________________________________________________________________________
________________________________________________________________________________________________________________________
Is this patient still home bound
: Yes No Reason: ___________________________________________________________________
Clinical Findings:
Vital Signs: Before Pulse___/min BP___/___ RR___/min After Pulse___/min BP___/___ RR___/min
Pain: Severity Level: 0 1 2 3 4 5 6 7 8 9 10 Location:________________________________________________________________________
ROM: __________________ Muscle strength: Improved/Decreased: _______________________________________________________
WB Status: _______________
Current Functional Status
Functional
Assessment
Ind Sup CG Min Mod Max Dep NA
Comments and Training done
Bed mobility
Supine to sit
Transfer i/o of
bed
Bed to chair
Sit to stand
Toilet/commode
Shower/tub
transfer
Orthosis/
prosthesis
Ambulation Ind Sup VC CG Min Mod Max A Device Distance
Indoors
Outdoors
# of stairs
Gait Deviations and Training: _________________________________________________________________________________
_________________________________________________________________________________________________
___________
Progressive Balance and Coordination Training:
Sitting - Static: ___ dynamic___ Standing: Static:___ dynamic___ Leaning forward___ Reaching over___ single leg stance___ Side step
__ Backward walk__ Alternating Motion__ Reciprocal motion__ Sequence activities__ Movement activities
Other___________________________________________________________________________________________________________________
Progressive Therapeutic Exercise: ___PROM ___ AAROM___ Resistive Strengthening ___Non Resistive Strengthening
___ Stretching exercises ___Joint mobilization