Physical Therrapy What Is the Difference Between a Systems Review and a Review of Systems

A physical therapy evaluation is the synthesis of all the information you gather during a physical therapy examination. Oft, Physical Therapy "evaluation" and "exam" are used interchangeably when referring to the patient's get-go encounter with a Physical Therapist. In this commodity, we'll discuss the components necessary to write a concrete therapy evaluation as well as the basic structure of an test. You lot can also download a physical therapy evaluation instance to use as a template.

Physical Therapy Evaluation 101

If you're a student PT or a new grad Physical Therapist, you're probably familiar with a concrete therapy evaluation. But let's make sure you really know the why and the what before we get into the how .

Evaluations. The Why:

Physical Therapy evaluations are generally the first run into y'all have with a patient and sets the expectations for the rest of the plan of care, or the fourth dimension yous anticipate seeing the patient. The evaluation documentation you create following the patient's initial evaluation becomes a part of the patient's medical records, forth with the notes from every subsequent visit.

These records are important considering other therapists, physicians, and even the patient's health insurance company may reference your notes in the hereafter. The patient may besides asking to see their therapy notes, and then writing authentic and thorough documentation is important.

Evaluations. The What:

Let's break information technology down into two parts: clinical examination and the written therapy evaluation.

Clinical Examination: Near clinics will ready aside 45 to lx 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 & Musculus Strength Testing
Special Tests
Abode Do Prescription
Goal Setting
Treatment Recommendations

For an in depth expect at how to structure your PT eval, check out the Therapy Evaluation Templates

Written Evaluation: Later the clinical evaluation is completed, you'll demand to finalize the encounter with documentation. This involves typing up your study that includes all your findings too every bit your professional assessment of the patient and why they demand therapy. The written evaluation may take anywhere from xv to 45 minutes to complete after yous're done with your visit, depending on how much information you lot were able to certificate during the visit and whether or not your system is easy to use.

The residual of this article will focus on writing your evaluation and using concrete therapy evaluation template forms and therapy evaluation examples to help yous write improve notes in less time.

Physical Therapy Evaluation CPT Code

In 2017 the CPT codes for therapy evaluations inverse to reverberate different tiers or evaluation levels.

Based on factors such as patient history, test, clinical presentation, and clinical decision making skills, you can select a low, moderate, or loftier level evaluation CPT code.

Concrete Therapy Evaluation CPT Codes

97161 – Depression Complexity

97162 – Moderate Complexity

97163- High Complication

97164 – PT Re-Evaluation

Occupational Therapy Evaluation CPT Codes

97165 – Low Complexity

97166 – Moderate Complication

97167 – Loftier Complexity

97168 – OT Re-Evaluation

Choosing an evaluation CPT code is not simply a matter of how much time you spent with the patient. While time spent with the patient is a contributing factor (20, 30, 45 minutes for low, moderate, high complexity), it is not a requirement or the only gene to consider.

Selecting an Evaluation Complication Level

Every bit you lot tin can see in the nautical chart below, selection of a low, moderate, or loftier level evaluation CPT code will depend on these key factors:

History
Examination
Clinical Presentation
Clinical Decision Making Skills

As of 2020, CMS has not released a tiered reimbursement based on the tiered evaluations. PT evaluations are reimbursed at the same level every bit of now. It's expected they volition brand changes with this data, but nothing moves fast with CMS.

While it's important to accurately document your findings and to perform a thorough evaluation, there is not a 'penalization' for selecting a low complexity eval, moderate or loftier complexity eval. They've tried to make the selection procedure as objective as possible, but there will be overlap in stance equally to what classifies equally depression, moderate, or high. Exercise your best and only select an eval code and move on. If nosotros spend 5 minutes mulling over the complication of the eval, we can miss the forest for the trees.

Physical Therapy Examination

Earlier we can fifty-fifty brainstorm writing a therapy evaluation, we need to become an idea of what the test catamenia will look like.

Earlier the Exam Starts

Before yous even meet the patient, there's a skilful chance you'll accept the opportunity to look over the patient intake grade. A adept patient intake form will give you lot a concise roadmap that should help identify some of the major problems, which may lead you to inquire farther questions during the bodily exam.

Initial Introduction

Your first impressions with the patient tin impact the rest of the evaluation and treatment session. In the Evaluation Templates, I share my exact formula for putting patients at ease and the wording I use to help my evaluations flow as smoothly as possible. While you shouldn't write out every question you plan on asking the patient, you should be able to talk conversationally and lead the exam equally you try to observe the best handling plan for the patient.

Patient History

Ane of the get-go elements covered in a physical therapy evaluation is the patient's medical history. Equally the concrete therapist, be very mindful how you nowadays the question asking well-nigh the patient's medical history. Exist careful what yous ask for, otherwise you lot might feel like you're spiraling down a path of information that may not exist relevant for you at this very moment. Exist direct and ask the patient about pertinent medical history and the events that led up to the reason they're seeking physical therapy today.

Systems Review

As you start to assemble information from the patient during your exam, you'll be able to narrow in with specific questions to identify how various body systems are involved. Your critical thinking skills will come into play here as you remember through various systems from neuromuscular to cardiovascular and integumentary. Your understanding of how these body systems respond based on the symptoms and presentation of your patient will be important to think through as you develop a physical therapy diagnosis and plan for treatment.

Concrete Therapy Tests & Measures

During the exam, yous'll employ a diverseness of special tests and measurement tools to gather relevant information near the patient. From ROM (range of movement) to MMT (manual musculus testing) and neuro screening tests, you'll tailor your exam based on the individual patient. It's important to also realize that a thorough exam doesn't mean performing every special test available. Your power to efficiently get together information during the time you accept with the patient will improve with time.

Presentation of Findings

Every bit you progress through the examination, you will showtime to develop an understanding of key factors contributing to the patient's pain, discomfort, or overall functional limitations. It tin exist helpful to briefly summarize your initial impression with the patient to share a prognosis and plan for their intendance. As you lot nowadays your findings, be mindful that people respond differently, fifty-fifty if information technology's a routine injury like an ankle sprain or a major surgery like a total joint replacement.

Handling Recommendations

Part of the initial concrete therapy visit may include treatment intervention performed during the session. Information technology's common for a physical therapist to place specific movements and helpful exercises based on the patient's clinical findings, then providing a list of dwelling exercises is commonly washed at the end of the session.

The concrete therapist will also use this time to set an expectation of visit frequency and recommended handling which may correspond to the general recommendations provided on the dr.'southward script for PT.

Writing a Physical Therapy Evaluation

After the concrete therapy initial evaluation visit is finished, you'll need to write upwardly the written evaluation.

In almost every clinic I've worked in, the electronic medical record (EMR) immune me to type and document during the visit. This gave me a head get-go in completing the evaluation, saving valuable fourth dimension afterwards.

Having a framework for your exam will help you to become more efficient as you document your evaluation findings on the computer while y'all're with the patient.

Completing 100% of the evaluation during the patient visit usually doesn't happen.

You tin expect to spend anywhere from fifteen to 45 minutes typing an evaluation later the visit is finished.

Key Components of a Physical Therapy Evaluation

While the overall structure of a physical therapy evaluation does follow a wide Lather note format, you lot'll cover a lot more than detail in this initial note than in nearly follow up notes or daily notes.

Subjective / Primary Complaint / By Medical History

I of the starting time sections of any written evaluation volition allow the therapist to document relevant information about the patient and why they are seeking therapy in the first place. While some EMRs rely heavily on checkboxes and drop down pick, you lot're likely to see a free-text section where yous tin can write out a patient subjective and past medical history.

Here'due south an case of ane:

The patient is a 62 year erstwhile female who presents with complaints of right human knee hurting s/p TKA performed on 11/29/18. The patient reports having knee pain for years earlier she consulted with an ortho surgeon in Baronial of 2018. An Xray revealed astringent arthritis and the patient elected to undergo full knee replacement in Nov of 2018. The patient reports the surgery was performed with no issue. She was released home afterwards a one dark stay at the hospital. The patient lives with family unit who is able to assist with driving her to appointments until cleared by physician to bulldoze. The patient's goals are to return to working equally a college administrator this spring, and to 'walk without a walker or cane equally soon as possible."

Objective Testing / Special Tests / Relevant Data

During the initial evaluation, you'll gather a lot of information that volition serve as a 'baseline' to compare confronting equally you progress the patient towards their goals. While you may not be able to get to every test during this initial treatment, yous volition even so document your findings along with any other relevant information from outcome measures or forms the patient completed in their initial paperwork.

Interested in learning more about special tests? Visit our Special Tests page.

Therapy Assessment, Diagnosis, Prognosis, & Goals

The next section of the written evaluation volition cover the overall cess, diagnosis, and prognosis equally well as goals. This section specifically answers the question, "why does this person need physical therapy right now." This department answers that question and uses the information gathered through the examination to put the finishing touches on the evaluation.

Plan of Care

The evaluation volition generally finish with a reference to a plan of care. This outlines the frequency of visits you recommend equally well as the potential treatment options y'all expect to provide during the entire plan of care. Many states likewise as insurance companies crave the doc to sign this section in club to corroborate the PTs recommended treatment.

Want a Total Physical Therapy Evaluation Form?

Take a wait at my therapy notes with a full text physical therapy evals and sample assessments that will aid you relieve thirty to lx minutes a day.

What'southward Included in this PT Eval Form Template?

Fully Customizable Patient Intake Questionnaire (Google Doc)
4 Total-Length Example Evaluations (Real Examples)
4 Fully Customizable Blank Evaluation Templates (Google Doc Format)
Efficient Evaluation Guide
BONUS – Fully Customizable Progress / Discharge Template
BONUS – x Subjective Interview Questions

These physical therapy evaluation templates provide you with real, total-length evaluation examples used in actual therapy documentation.

You tin re-create and paste straight from the PDF, and modify the phrases to fit your documentation style and to reflect the skilled treatment you've provided.

These templates simply requite you the creative catamenia that you may exist defective at the end of a long 24-hour interval treating patients.

Yous can spend an extra 30-threescore minutes a twenty-four hours typing similar evaluations and assessments over and over. Or you tin modify these templates to create a time-saving system for documenting your skilled handling.

These templates are a must-accept for new grads or current therapists who want to save time so they tin can savor their life outside of the clinic.

Come across the entire packet of evaluation and documentation templates:

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Source: https://www.ptprogress.com/physical-therapy-evaluation/