Inpatient Evaluation EMR DPT

Patient & Encounter Information

Patient Identifier / Name:

Admit Date:

SOC Date:

Onset Date:

Primary Diagnosis:

Physician Order/Reason for Rx:

Plan of Care

Patient Caregiver Education (describe):

Precautions (describe):

Other (describe):

History

Current Medical History/History of Present Illness:

Current Surgical History:

Previous Medical History:

Previous Level of Function/Adaptive Equipment:

Home Environment/Social History:

Patient/Family Goals:

Barriers to Treatment/Education:

Objective Observation & Status

Pain (0-10):

If 6/10 or greater, nursing notified

Nurse Name:

Time Notified:

Mental Status:

Mental Status Notes / Visual Observation:

Sensation:

AROM / PROM

Joint	AROM	PROM
Shoulder/Hip
Elbow/Knee
Wrist/Ankle
Hand/Foot
Fingers/Toes

Functional Mobility & Motor

Coordination:

Motor (Strength):

Bed Mobility (Supine to Sit):

Sit to Stand:

Transfers:

Equipment Needs:

ADLs

Feeding:

Grooming:

Toileting:

Dressing:

Gait/WC Mob

Weightbearing (L/R, UE/LE):

Distance / Deviations / Device:

Assessment & Goals

Assessment:

Short Term Goals (Target Days: )

1. Supine Sit

2. Sit Stand

3. Ambulation

4. Distance / Device / Weightbearing

5. Range of Motions

6. HEP (Home Exercise Program)

7. Precautions Recall & Demonstrate

8. ADL's

9. Caregivers/Patient Education

Additional Patient Specific Goals:

Discharge Planning & Attestation

Rehab Potential:

Estimated Days:

Recommended D/C Disposition:

By checking this box, the therapist acknowledges that the patient agrees to the above plan of care. Additionally, if feasible, alternative interventions to the plan were discussed with the patient/family prior to the patient agreeing to the above plan. Patient/family declined to proceed with the therapy plan of care. PT Signature: