How To Write a Physical Therapy Evaluation

A physical therapy evaluation is the synthesis of all the information you gather during a physical therapy examination. Let's review a physical therapy examination and how to write up your findings in a physical therapy evaluation.
You can find all the templates here:
Evaluation Template: www.ptprogress.com/eval
Assessment/Goal Template Bundle: www.ptprogress.com/templates
Thanks to MedBridge Education for providing $175 off with the promo code PTProgress. www.medbridgeeducation.com/pt...
💡Efficient Therapy Documentation Course ✏️ www.ptprogress.com/efficient
😲 It’s how I save 30-60 minutes a day on documentation ⏰
Timestamps:
0:00 - Intro
1:00 - What is a Therapy Evaluation?
3:28 - Clinical Examination
8:54 - Written Evaluation
14:53 - Full Evaluation Example
Clinical Examination: Most clinics will set aside 45 to 60 minutes for the initial evaluation. During the evaluation, you’ll cover a lot of information, which may include:
Patient’s Medical History
Systems Review
Tests & Measures
Posture & Gait Analysis
Range of Motion & Muscle Strength Testing
Special Tests
Home Exercise Prescription
Goal Setting
Treatment Recommendations
For an in depth look at how to structure your PT eval, check out the Therapy Evaluation Templates
Key Components of a Physical Therapy Evaluation
While the overall structure of a physical therapy evaluation does follow a broad SOAP note format, you’ll cover a lot more detail in this initial note than in most follow up notes or daily notes.
Subjective / Chief Complaint / Past Medical History
Objective Testing / Special Tests / Relevant Data
Assessment, Diagnosis, Prognosis, & Goals
Plan of Care
**Disclaimer**
The content found on this channel and any affiliated websites are not considered medical or financial advice. The information presented is for general education and entertainment purposes only. If you need medical attention, seek care from your physician or physical therapist. You agree to indemnify and hold harmless PTProgress, its employees, officers, and independent contractors for any and all injuries, losses, or damages resulting from any claims that arise from misuse of the content presented on this channel or associated websites. Some of the links above may be affiliate links, which help support the channel but does not cost you anything.

[@PTProgress]

Curious to know: How long does it take you to write your evaluations?

[@vikkigaines9836]

Simple eval ~60min with point of service documentation. Those make my heart happy. Complex eval can take an additional 60 min. That doesnt include all the f/u calls, paperwork needed.

[@timsalkowski8610]

@@vikkigaines9836 hold up... did you say it takes you 60 minutes to WRITE an eval?

[@awong160]

As someone who is currently shadowing at an outpatient clinic, I really enjoyed this video! Thank you!

[@noonnhh]

Good words good information good explanation, I’m proud of you that you explained very carefully

[@ericossian228]

Current athletic training student who hopes to attend PT school in the future! Thanks for all your videos!

[@PTProgress]

Thanks for watching Eric!

[@ahmedabdelhadi9272]

Great content appreciate it

[@lysu80]

thank you.. your information is very interesting. so let me introduce myself, I'm Lily Suwanti. I'm a physical therapist from Indonesia. I enjoy watching your channel. I hope we can discuss & share experiences. good job 🙏

[@allissab4915]

Will this also help if I use WebPT?

[@nicholasdagostino189]

Is access to the templates included when you purchase the efficient documentation course?

[@PTProgress]

Yes they are!

[@mikenowitzki6732]

Hi. We’re adding an OT to our practice. Any tips filling out that CMS 855B form?