How To Use a Physical Therapy Evaluation Template in 5 Steps

Do you ever get the feeling that perhaps you're spending more time on paperwork than actually treating your patients? You probably do. Although physical therapy evaluations are essential for crafting effective treatment plans, the documentation process can be a time-consuming beast—especially if you run a busy clinic!

Thankfully, physical therapy evaluation templates exist to streamline assessments and free up valuable time so that you can return to what matters most: your patients' well-being. 

This short but insightful guide will walk you through the steps for using a physical therapy evaluation template effectively. We'll cover what an evaluation form includes and how to customize it for your specific needs so you can deliver comprehensive patient care without sacrificing precious time. 

We'll also learn about Empower EMR's documentation software, which offers customizable EMR templates as the perfect solution for creating efficient and compliant documentation for every clinical presentation. So hang tight! 

Main Takeaways From This Article:

• Understanding the distinction between physical therapy evaluation and examination helps clarify the full assessment process.
• Key components of a physical therapy evaluation form include patient identification, patient's medical history, current condition, and functional limitations.
• Setting SMART goals within evaluations helps in creating clear, measurable, and achievable treatment plans.
• Customizing a physical therapy evaluation template ensures it meets specific practice needs and patient scenarios.
• Empower EMR's customizable templates streamline documentation for both efficient record-keeping and compliance to help you offer skilled physical therapy services.

Physical Therapy Evaluation vs. Examination

First, let's clear up a common point of confusion. A physical therapy evaluation involves both the examination and the analysis of the findings. Although the terms are often used interchangeably, they are certainly not the same. 

• The examination phase is typically the initial step in a care plan, during which the physical therapist gathers comprehensive data through subjective and objective measures. Subjective measures involve collecting information from the patient about their medical history, current symptoms, and overall health status. Objective measures involve physical assessments like range of motion tests, muscle strength evaluations, and functional assessments. 
• Once the examination is complete, the therapist moves on to the evaluation phase. Here, they interpret the findings from the examination and synthesize this information to make clinical judgments. This stage involves analyzing the collected data to understand the underlying causes of the patient's issues, which allows the therapist to diagnose the condition, determine its severity, and decide the most appropriate interventions. 

While the primary goal of PT examination is to identify and quantify a patient's functional limitations and impairments, the evaluation helps formulate a personalized treatment plan based on the patient's specific needs, which may include therapeutic modalities and exercises. 

What Does a Physical Therapy Evaluation Form Include?

The exact content of a physical therapy evaluation form will vary depending on your practice and the patient's specific condition. However, most forms typically cover these key areas:

• Patient Information: Basic details like name, address, date of birth, etc.
• Medical and Surgical History: Past medical history about surgeries, injuries, medications, and any relevant diagnoses.
• Chief Complaint: The main reason why the patient is seeking physical therapy.
• History of Present Illness: A detailed description of the current condition, including how it started, its severity, and any pain characteristics.
• Family History: Any relevant medical conditions in the patient's family.
• Functional History: How the condition affects the patient's daily activities.
• Social History: Occupation, living situation, and lifestyle factors that might impact their recovery.
• Systems Review: A general check of all bodily systems for any potential red flags.
• Physical Examination: Findings from tests assessing range of motion, strength, reflexes, sensation, gait, and posture.
• Assessment and Plan: Your interpretation of the findings, including a diagnosis (if applicable) and proposed treatment plan with specific goals.
• Treatment Goals: Measurable objectives for the patient's recovery.
• Prognosis: Your educated prediction for the patient's course of treatment.

How To Use a Physical Therapy Evaluation Template in Five Simple Steps

Now, let's get down to business and see how you can use a physical therapy evaluation template to its full potential:

1. Select the Right Template

One size doesn't fit all when it comes to evaluation templates. Here are some factors to consider when choosing the perfect one for your needs:

• Practice Focus: Are you a general practice PT, or do you specialize in areas like pediatrics, sports medicine, or neurology? Select a template that aligns with your typical patient population.
• Content Specificity: Do you require specific sections for unique evaluation techniques you frequently use? Explore templates that offer customization options or built-in sections for these practices.
• Workflow Compatibility: Consider how the template integrates with your existing workflow. Opt for a digital template within your Electronic Medical Records (EMR) system for seamless data entry and recordkeeping.

2. Customize Your Template

The beauty of templates lies in their adaptability. Don't be afraid to personalize the template to fit your practice's needs and preferences. Here's how you can do this:

• Add Specific Sections: Does your practice utilize specific evaluation techniques that aren't included in the template? Most templates allow for customization, so incorporate dedicated sections for these assessments.
• Modify Wording: While the template's core structure is helpful, feel free to adjust the wording in sections like "History of Present Illness" to match your preferred phrasing for collecting patient information.
• Integrate Drop-Down Menus: For frequently used terms or diagnoses, consider incorporating drop-down menus to streamline data entry and improve consistency.

3. Document Assessment Findings

This is where the template truly shines. Your physical therapy evaluation template serves as a springboard for efficiently documenting your observations and findings from the examination. 

Utilize the predefined sections to record details about:

• Posture and Gait Analysis: Observe the patient's alignment, balance, and walking pattern. Note any abnormalities or limitations.
• Range of Motion: Test and document the movement capabilities of affected joints using a goniometer or visual observation.
• Muscle Strength: Assess muscle power using manual muscle testing or functional movements.
• Pain: Record the location, character, severity, and aggravating/easing factors of the patient's pain.
• Neurological Function: Evaluate reflexes, sensation, and coordination, noting any deficits.
• Special Tests: Include results from specific tests relevant to the patient's condition.

Note: The template is a guide, not a straitjacket. Don't be afraid to deviate for unique situations, but having a structured framework saves time and ensures you capture essential details consistently.

4. Set Treatment Goals

Collaboration is key to successful treatment! This part of the evaluation should involve working with your patient to establish clear, measurable goals for their recovery. Here's how you can approach this step:

• Focus on Function: Prioritize goals that translate to improvements in daily activities. Aim to regain pain-free gait, improve balance for fall prevention, or facilitate a return to work or hobbies.
• Set SMART Goals: Make sure your goals are Specific, Measurable, Achievable, Relevant, and Time-bound. For example, a patient recovering from a knee injury might have a goal of "increasing pain-free walking distance by 100 meters within four weeks."
• Document Jointly: Actively involve your patient in setting goals. Their input ensures the goals are relevant and attainable, fostering a sense of ownership and engagement in their recovery process.

5. Review and Finalize

Before hitting 'Submit', take a moment to thoroughly review the evaluation for accuracy and completeness. Here's what you should do:

• Ensure All Sections Filled: Double-check that all sections of the template are filled out with relevant information. Don't leave any blanks!
• Attach Supporting Documentation: If necessary, attach any supporting documentation, such as imaging reports or previous treatment records, to the evaluation.
• Proofread and Sign: Proofread the entire document for any typos or grammatical errors. Once satisfied, finalize the evaluation with your electronic signature or a physical signature for paper forms.

By following these steps, you can leverage physical therapy evaluation templates to create efficient, comprehensive documents that enhance patient care.

The Bottom Line: Optimize Evaluations With Empower EMR

You now know that physical therapy evaluation templates are a game-changer for streamlining documentation and creating comprehensive patient assessments. But what if you could unlock even greater efficiency and improve the overall patient experience with an easy-to-use tool?

Empower EMR's PT practice management software offers a suite of customizable templates that are specifically designed for physical therapy practices. Some of our key features include:

• Electronically Capture Patient Information and Assessments: Say goodbye to paper charts and hello to a more streamlined workflow!
• Utilize Pre-Populated Templates for Common Conditions: Save even more time by using pre-populated templates for frequently encountered conditions. These templates can be further customized to fit your specific evaluation style.
• Integrate Outcome Measures: Track patient progress with ease by integrating standardized outcome measures directly into your evaluations.
• Generate Reports With Ease: Effortlessly create reports for patients, physicians, and insurance companies with a few clicks.
• Collaborate With Patients Virtually: There is no need to wait to meet your patients in person! Simply share their treatment plans and progress notes through a secure online portal for a seamless experience.

By leveraging our comprehensive solution, you can transform your documentation process, optimize patient care, and ultimately dedicate more time to what matters most – helping your patients achieve their physical therapy goals.

Want to experience the software firsthand?

Book a Demo Now!