Physical Therapist Eval Forms: 11 Tips to Optimize Documentation

They say your first step is the most important one. This sentiment certainly applies to the physical therapy field—namely when it comes to evaluating patients during their initial visit.

A misstep during the evaluation process can not only set patients on the wrong path to recovery, but can also make it difficult to get reimbursed by insurance companies. That’s why choosing the right physical therapist evaluation forms is paramount to both patient and physician success.

Keep reading to learn more about the evaluation process, associated eval forms (which might look something like this), and how you can improve your forms to maximize patient outcomes and ensure reimbursement.

Breaking Down the Physical Therapy Evaluation

What Is a Physical Therapy Evaluation?

A physical therapy evaluation is a comprehensive assessment conducted by a physical therapist to understand a patient’s current condition, functional limitations, and pain levels. It serves as the foundation for developing an individualized treatment plan tailored to the patient’s specific needs and goals.

Key Components of a Physical Therapy Evaluation

Physical therapy evaluations consist of several key components, including:

• Subjective history. This involves a detailed conversation with the patient to gather information about their medical history and current symptoms, as well as how their condition impacts their daily activities. The therapist may ask questions about the onset of symptoms, pain characteristics, previous treatments, and any relevant medical conditions.
• Objective examination. This component focuses on a hands-on assessment of the patient’s physical abilities like the following.
  • Postural assessment: Evaluating the patient’s posture and alignment to identify any deviations or imbalances that may contribute to pain or dysfunction.
  • Range of motion (ROM) assessment: Measuring the extent of movement in specific joints to assess flexibility and identify limitations.
  • Strength testing: Evaluating muscle strength through manual muscle testing or using specialized equipment to determine the patient’s ability to generate force.
  • Neurological examination: Assessing sensory function, motor control, and coordination to identify any neurological deficits that may be contributing to the patient’s condition.
  • Special tests: Performing specific tests to diagnose various conditions or identify the source of pain, such as orthopedic tests for joint injuries or neurological tests for nerve-related issues.
• Functional assessment. This involves evaluating the patient’s ability to perform activities of daily living (ADLs) and functional tasks. The therapist may observe the patient performing tasks such as walking, climbing stairs, lifting objects, or getting dressed.
• Diagnosis. Based on the information gathered during the subjective history and objective examination, the physical therapist will formulate a diagnosis, which may include a primary diagnosis, secondary diagnoses, and contributing factors.
• Prognosis. The therapist will estimate the patient’s potential for recovery and recovery time based on their condition, age, overall health, and adherence to the treatment plan.
• Goal setting. In collaboration with the patient, the therapist will establish specific, measurable, achievable, relevant, and time-bound (SMART) goals to guide the treatment process.
• Treatment plan development. The therapist will develop a customized treatment plan that outlines the specific interventions, modalities, and exercises to be used to address the patient’s impairments and functional limitations. The treatment plan may include a combination of manual therapy techniques, therapeutic exercises, modalities such as heat or cold therapy, and patient education.

The Importance of a Physical Therapy Evaluation

Physical therapy evaluations are critical for patient care because they help with:

• Diagnosis accuracy. A thorough evaluation helps identify the underlying cause of a patient’s pain or dysfunction, leading to an accurate diagnosis. This is essential for developing an effective treatment plan.
• Treatment plan personalization. By understanding a patient’s specific needs and limitations, you can create a customized treatment plan that maximizes their potential for recovery.
• Goal setting. Evaluations help establish realistic and achievable goals for the patient, which can motivate them and track their progress throughout therapy.
• Progress monitoring. Regular evaluations allow you to monitor a patient’s progress towards their goals and make necessary adjustments to the treatment plan.
• Prevention of future injuries. By identifying potential risk factors and weaknesses, you can provide preventive strategies to help patients avoid future injuries or re-injuries.
• Improved function and quality of life. Ultimately, physical therapy evaluations aim to help patients regain their function, reduce pain, and improve their overall quality of life.

What You Need to Know about Physical Therapist Evaluation Forms

Types of Evaluation Forms

The specific types of physical therapist eval forms can vary depending on the healthcare facility, insurance provider, and individual therapist’s preferences. However, most forms will include similar sections to capture essential information about the patient and their condition.

Some common eval form types include:

• General evaluation form
• Orthopedic evaluation form
• Neurological evaluation form
• Geriatric evaluation form
• Pediatric evaluation form

The general evaluation form is a versatile document that can be used for a wide range of patients. It typically includes sections for:

• Patient demographics
• Medical history
• Current condition and symptoms
• Functional limitations
• Goals of treatment
• Objective findings (e.g., ROM, strength, sensory testing)  
• Treatment plan

The orthopedic evaluation formis specifically designed for patients with musculoskeletal conditions. It may include additional sections for:

• Injury mechanism
• Pain location and characteristics
• Joint stability testing
• Specific orthopedic tests (e.g., Lachman’s test, McMurray’s test)

The neurological evaluation form is used for patients with neurological conditions or suspected neurological involvement. It may include sections for:

• Cognitive function
• Balance and coordination
• Sensory testing
• Reflex testing
• Gait analysis  

The geriatric evaluation form is tailored to older adults and may include additional sections for:

• Functional independence measures (e.g., Barthel Index, Katz Index)
• Fall risk assessment
• Cognitive screening
• Social history

The pediatric evaluation form is used for children and adolescents and may include sections for:

• Developmental milestones
• Pediatric-specific tests (e.g., Gross Motor Function Measure, Pediatric Evaluation of Disability Inventory)
• Family and social history

These are just a few examples of eval forms you may use as a physical therapist, and the specific content and format of evaluation forms can vary. Ultimately, the goal of a physical therapist eval form is to provide a clear and concise record of the patient’s condition, treatment plan, and progress.

Choosing the Correct Evaluation Form

Choosing the most appropriate evaluation form for a specific patient depends on several factors, including:

• Patient’s primary diagnosis. Different conditions require different types of evaluations. For example, a patient with a knee injury would benefit more from an orthopedic evaluation form, while a patient with a stroke would require a neurological evaluation form.
• Patient’s age and developmental stage. Pediatric patients may require specific evaluation forms that consider their developmental milestones and unique needs. Similarly, geriatric patients may need forms that address age-related changes and functional limitations.
• Complexity of the patient’s condition. For patients with complex issues or multiple coexisting health conditions, a more comprehensive evaluation form may be necessary to capture all relevant information.
• Clinical setting. The specific setting where the evaluation is conducted (e.g., outpatient clinic, hospital, home health) may influence the choice of form. Some settings may have specific requirements or preferences for documentation.
• Therapist’s clinical expertise and preferences. Depending on your specific experience as a physical therapist, you may have your own preferred evaluation forms or templates that you find effective and efficient.

Evaluation Form Information

What’s included in a physical therapist eval form? Generally, these forms include some combination of:

• Patient demographics, like name, age, gender, address, contact information, and insurance information.
• Referring physician’s name, address, and contact information.
• Chief compliant compelling them to seek physical therapy.
• Present illnesses and their duration, location, intensity, etc.
• Past medical history, including relevant medical conditions, surgeries, and medications.
• Social history, including occupation, hobbies, and lifestyle factors.
• Functional limitations regarding the ADLs impacted by their condition.
• Vital signs such as heart rate, blood pressure, and temperature.
• Postural assessment data like alignment and deviations.
• ROM measurements for all relevant joints.
• Strength testing grades for major muscle groups.
• Any special test results, such as ones for orthopedic or neurological tests.
• Pain assessment using a standardized pain scale (e.g., numeric rating scale, visual analog scale).
• Primary and secondary diagnoses, if applicable.
• Any impairments in bodily function and structure.
• Prognosis of estimated potential for recovery and expected timeline.
• Plan of care including short- and long-term goals, interventions, frequency and duration of treatment, and discharge planning.

This is a broad list of data points you may find on an evaluation form. Your form may include more or less information depending on a number of factors we’ve discussed here.

11 Tips to Optimize Physical Therapist Eval Forms

1. Prioritize Clarity and Conciseness

Focus on the essential details and avoid unnecessary information that may clutter your documentation. Use simple language, and avoid medical jargon, especially when communicating with patients or non-healthcare professionals.

2. Use the SOAP Note Format

SOAP (Subjective, Objective, Assessment, Plan) is a structured format that provides a clear framework for organizing your thoughts and ensuring comprehensive documentation. Here’s what you should include in a SOAP note:

• The subjective section should include the patient’s chief complaint, history of present illness, and relevant medical history.
• The objective section should detail the results of your physical examination, including tests and measurements.
• The assessment section should summarize your findings and diagnosis.
• The plan section should outline your treatment goals and interventions.

3. Be Specific and Objective

Use precise terms to describe the patient’s condition and functional limitations. Avoid vague or subjective language. For example, instead of saying “patient has pain,” specify the location, intensity, and type of pain (e.g., “patient reports a sharp, 8/10 pain in the right knee”).

4. Employ Standardized Abbreviations

Use widely recognized abbreviations to save time and space, but only if they are clear and unambiguous. Refer to a standardized abbreviation list to ensure consistency and avoid confusion.

5. Proofread Meticulously

Check for errors in grammar, spelling, and punctuation. A well-written evaluation reflects professionalism and attention to detail.

6. Embrace Active Voice

Active voice makes your writing more direct and easier to understand. For example, instead of “The patient was assessed by the therapist,” write “The therapist assessed the patient.”

7. Leverage Headings and Subheadings

Organize your documentation visually to improve readability and clarity. Use headings and subheadings to separate different sections of the evaluation, such as subjective history, objective examination, and treatment plan.

8. Maintain Consistent Formatting

Use consistent font styles, sizes, and spacing throughout your documentation. A consistent format makes your evaluation easier to read and understand.

9. Consider Your Audience

Tailor your documentation to the specific needs of your readers, such as other healthcare providers or insurance companies. For example, when writing for insurance purposes, be sure to include all relevant codes and documentation to support reimbursement.

10. Use an EHR

Electronic health records (EHRs) can significantly streamline and improve the process of completing physical therapist eval forms. These solutions typically have a collection of physical therapy evaluation templates you can start from to save time. EHRs also have data integration and clinical decision support capabilities that further enhance the evaluation process.

11. Review and Update Regularly

Ensure your documentation is accurate and up to date by reviewing and revising it as needed. As the patient’s condition changes, update your documentation to reflect their progress and any modifications to the treatment plan.

Give Physical Therapist Eval Forms Your All

Though you surely understood the importance of eval forms, the above information should help you improve your patient evaluation process and the associated documentation tasks, ultimately producing better patient outcomes and ensuring you are reimbursed properly for your efforts.