Physical Therapy Evaluation/Discharge Summary:

Neurological PRECAUTIONS:

Diagnosis: _______________________________________________

Reason for Referral: __________________________________

Pertinent Medical History:
__________________________________________________________________________________
______________________________________________________________

Social/Home/Language:
__________________________________________________________________________________
______________________________________________________________

Prior Level of Function: ____________________________________________________

Equipment Owned: _______________________________________________________

General Observations/Orientation:
[ ] Foley [ ] SCD’s [ ] O2 @[ ]Ltrs/Min [ ] Drain:
[ ] Incision [ ] Intubated [ ] TEDS
[ ] Family at bedside [ ] Telemetry [ ] Other:
[ ] IV [ ] PCA

Patient/Family Goals for PT: ________________________________________________

________________________________________________________________________

Cognition/Behavior: [ ] Ready to learn, no barriers

__________________________________________________________________

Learning Preference: [ ] Verbal [ ] Written [ ] Demo

[ ] Other/Comment:

Pain: Y / N
Location:
Intensity:
Quality/Characteristics:
Aggravating/Easing Factors:
History:
Comments:

OBJECTIVE:
Functional Mobility:
KEY: I=Independent; VC/S=Verbal Cues/Supervision; SBA=Stand By Assist;
CG=Contact Guard; Min=Minimal Assist (75-100%); Mod=Moderate Assist (50-
74%); Max=Maximal Assist (25-49%); N/A=Not Applicable
Rollin: Stand Balance:
Static:
Scooting: Dynamic:
Gait:
Supine <-> Sit:
Chair Transfer:
Sit Balance:
Static: Toilet Transfer:
Dynamic:
Stairs:
Sit <-> Stand:
Other:

ROM: Range of Motion:

R UE: [ ]WFL, [ ]except:

L UE: [ ]WFL, [ ]except:
R LE: [ ]WFL, [ ]except:
L UE: [ ]WFL, [ ]except:
Trunk:

STRENGTH:
R UE: [ /5]Grossly, [ ]except:
L UE: [ /5]Grossly, [ ]except:
R LE: [ /5]Grossly, [ ]except:
L LE: [ /5]Grossly, [ ]except:
Trunk:
Synergy Dependence:

Integument:

Neuro Status:
Coordination:
Purposeful Movements:
Tone:
Sensation: [ ] intact [ ] except:
Proprioception: [ ] intact [ ] except:
Clonus:
Babinski:

Vision: [ ] WFL [ ] Corrective Lenses

[ ] Acuity [ ] Inattention [ ]R [ ]L
[ ] Tracking Deficits [ ] Edematous Eyelid [ ]R [ ]L
[ ] Field Cut [ ] Depth Perception
[ ] Nystagmus [ ] Other:
[ ] Diplopia
Cranial Nerves: [ ]intact [ ]except:

Vital Signs Rest Activity

BP
HR
RR
ICP
Endurance
Subjective Sxs
(Dizziness, N/V,
other)
Other

PT Diagnosis:

PLAN/Assesment:
Problem List Goal (1 week) Intervention