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Oregon PT Initial Evaluations
Prior to initiating the first physical therapy treatment, a physical therapist shall perform an initial evaluation of each patient and determine a plan of care.
In the course of performing an initial evaluation the physical therapist shall examine the patient, obtain a history, perform relevant system reviews, assess the patient's functional status, select and administer specific tests and measurements and formulate clinical judgments regarding the patient. A physical therapist may incorporate by reference medical history or system review information about the patient prepared by another licensed health care provider and available in the physical therapy treatment record, IEP, IFSP or other designated plan of care.
A physical therapist shall perform a separate initial evaluation under the following circumstances:
Only a physical therapist may perform an initial evaluation. A physical therapist shall not delegate the performance of an initial evaluation to a physical therapist assistant or to an aide.
Documenting the Initial Evaluation
Minimal or Basic Treatment
Under circumstances or situations where a physical therapist is called upon to provide immediate minimal or basic treatment to a person participating in an athletic activity or event, the physical therapist shall examine the person by performing tests and measurements appropriate to the circumstances, assess the person’s condition, formulate clinical judgments, and determine the immediate care to be provided. Documentation shall include, at a minimum, the person’s name, age if available, a brief description of the injury or condition, and disposition or treatment, including recommendation for additional or alternative care. Neither a physical therapy plan of care nor a discharge summary is required in these circumstances.