"Home Care Physical Therapy Progress Note Template"

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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
On
□ 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:
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
On
□ 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: