3 Physical Therapy Assessment Documentation Examples

by Tim Fraticelli

The physical therapy assessment explains the ‘why’ behind the treatment provided and the response the patient had to that treatment. 

Strong therapy assessment phrases will result in two key items:

  1. It reveals the necessity of your skilled therapy

  2. It identifies key impairments to address in future sessions.

When writing therapy assessment documentation, try to include an overview of the patient’s ability (or challenge) in performing a certain task. If we relate the treatment back to a functional short-term or long-term goal, that makes for an even better assessment phrase!

Physical Therapy Assessment Documentation Examples

Whether you’re writing an assessment for a daily SOAP note, a progress note, or an evaluation, you’ll find this section to be the most involved section of your note-writing. That’s because it’s one of the most important areas we have to convey our skill as therapists! Use these examples below to help you to create efficiencies in your note-writing.

Let’s look at 7 therapy assessment documentation examples, starting with an evaluation.

Example of a Physical Therapy Assessment: Evaluation 

Here’s a simple outline to follow for the assessment portion of your physical therapy evaluation:

  1. Restate the patient’s diagnosis

  2. Comment on the patient’s rehab potential

  3. Identify the key impairments

  4. State why skilled therapy is necessary

Therapy Evaluation Assessment Example: 

Patient presents with signs and symptoms consistent with the medical diagnosis of Right Knee OA, s/p 1 week post operative R TKA. Rehab potential is excellent. Key impairments include: decreased ROM and strength of the right lower extremity, poor balance and compensatory gait pattern, increased swelling, and pain with functional activities such as squatting, walking, and navigating stairs. Skilled PT is required to address these key impairments and to provide and progress with an appropriate home exercise program. This evaluation is of moderate complexity due to the changing nature of the patient’s presentation as well as the comorbidities and medical factors included in this evaluation.

Interested in the full sample evaluation? Documentation templates and evaluation examples are included in the Therapy Evaluation Templates.

Example of a Physical Therapy Assessment: Daily Note

The assessment portion of a daily SOAP note doesn’t need to be a full paragraph, but it should be longer than a short sentence so it covers all the important elements of your skilled assessment. Identify the key components of the session relating to the patient’s impairments and goals. If you worked on balance training for example, your assessment needs to relate the ‘why’ behind your treatment. It wouldn’t make sense to spend most of your assessment on the patient’s joint mobility restriction if that wasn’t a key factor to their balance issue. 

Here are two examples of a SOAP note assessment:

Repeated trials of a single-leg stance on an uneven surface were effective in challenging the patient’s balance and resulted in improved stability at the end of the session. This was noted by an improvement to 8 seconds of unassisted single-leg stance.  

The patient demonstrates an unsteady gait without an assistive device. Verbal cueing to shorten step length and to control cane placement resulted in a safe gait pattern of 500 ft with stand-by assist. 

In these statements, we identify impairments that tie directly to the patient’s goals of improving their balance and walking independently and show how our involvement was essential to help them towards these goals.  

60+ Physical Therapy Assessment Documentation Examples

Sometimes it can be easy to get into a rut with our documentation. After a long day of treating patients, the last thing we want to do is to put on your creative writing hat and type for the next hour. 

In a typical day of 13 patients, imagine spending 10 minutes on each note. That’s over 2 hours of documentation! 

Saving even just 5 minutes per patient cuts down your documentation time by one hour every single day. 

What’s one hour of your workday worth? $40? $50? $60/hour?

In addition to saving time and money, the assessment templates I created were designed to give you the inspiration you need to create well-written assessments. These 60+ therapy assessment documentation examples will help you to write assessments that actually reflect the skilled therapy you provide on a daily basis. 

If you want to save time on your documentation, take a look at the therapy documentation bundle for the therapy assessment examples, goal examples, and more!

 

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