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.

Initial Evaluation

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:

• The patient is returning to care after being discharged from therapy;
• The patient is new to an inpatient or outpatient facility or home health agency; or
• A current patient presents with a new diagnosis for an unrelated body part.

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

Required information:

• Patient's full name, age and sex;
•  Identification number, if appropriate;
•  Referral source, including patient self-referral;
•  Pertinent medical or physical therapy diagnoses, medications if not otherwise accessible in another part of the patient's medical record, history of presenting problem and current complaints and symptoms, including onset date;
• Prior or concurrent services related to the provision of physical therapy services;
• Any co-existing condition that affects either the goals or the plan of care;
• Precautions, special problems and contraindications;
• Subjective information (patient's knowledge of problem);
• Patient's goals (with family input or family goals, if appropriate). Goals may be as
• Provided in an applicable IEP, IFSP, or other designated plan of care; and
• Appropriate objective testing results, including but not limited to:
• Critical behavior/cognitive status;
• Physical status (e.g., pain, neurological, musculoskeletal, cardiovascular, pulmonary);
• Functional status (for Activities of Daily Living, work, school, home or sport performance); and
• Interpretation of evaluation results.

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.

Citation

OAR 848-040-0125

OAR 848-040-0130