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The Evaluation portion of the initial note is a focal point of initial note documentation. The Evaluation section of the initial note is critical for a physical therapist, because one of its key purposes is to summarize the therapist's clinical judgments after examining the patient. This summary, in turn, will justify continued physical therapy intervention to third-party payors, if continued therapy services are deemed appropriate by the evaluating therapist. It also serves as a useful tool to other healthcare providers who want to read a brief summary of the deficits in function that were written elsewhere in the note. This information assists those providers to locate impairments and activity and participation restrictions listed in the sections of the note above the Evaluation section.1,2
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The Evaluation section of the initial note is a mandatory portion of every note. Its purpose is to support the need for skilled physical therapy intervention and assist therapists in obtaining justification for reimbursement for skilled therapy services from third-party payors. As a student with limited clinical experience, it can be difficult to formulate such an integrated paragraph as it requires prior clinical experience and resultant clinical judgment to do so. Therefore, for the purposes of explaining what components must be present in this portion of the note, we break down the Evaluation portion of the Assessment into the following components:
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Impairments of function and structure
Activity and participation restrictions
Personal factors
Environmental factors (physical environment and social support available) that are significant to the physical therapy care of the patient
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example
Case Patient: Mr. Torres
Location: Outpatient facility
Medical Diagnosis: Grade I tear in ® supraspinatus muscle (rotator cuff).
EVALUATION: Impairments: ↓ ® shoulder AROM, pain ® shoulder, weakness ® rotator cuff muscles. Activity & Participation Restrictions: Pt cannot reach into overhead cabinets or shelves or lift heavy tools (greater than 50# at times) needed for his job as a tree trimmer c̄ his ® UE. Cannot tolerate use of power tools c̄ his dominant ® UE. Personal factors: States he is motivated to return to work ASAP; no absences from work until current injury. Environmental factors: Cannot return to full duty until he is able to lift tools (greater than 50#), operate equipment safely using bilat. UEs, and pass a fit test; employer supportive of light duty.
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example
Case Patient: Mr. Johnson
Location: Inpatient rehabilitation facility
Medical Diagnosis: ® hemisphere stroke 2° to 20-yr. hx of uncontrolled HTN and type 1 DM.
A: EVALUATION: Impairments: ↓ AROM & strength Ⓛ hip, knee, ankle, & foot; Ⓛ foot lacks protective sensation, Ⓛ neglect c̄ visual perception deficits; ↓ attention to task, ↑ extensor muscle tone Ⓛ LE (distal greater than proximal). Activity & Participation Restrictions: Unable to amb. Personal factors: Hx of community involvement; motivated to return to community involvement/volunteer work. Environmental Factors: Lives alone in home c̄ 5 steps to enter ...