Assessment/Evaluation A discipline specific assessment/evaluation form will be completed to validate initial and reassessment requirements. The plan of care is developed in conjunction with the evaluation and must include: • Type of Modality/Procedures – Should describe the specific nature and frequency of the therapy to be provided such as, ultrasound, hot packs, whirlpool, and/or gait training. • Frequency of Visits – The frequency of therapy services to be rendered. • Duration – Length of time over which the services are to be rendered. May be expressed in days, weeks, or months. For example, “3w2” which means three times per week for two weeks. • Diagnosis – Should include the therapy diagnosis if different from medical diagnosis. For example, the medical diagnosis might be “Rheumatoid Arthritis”; however, the shoulder might be the only area being treated, so the therapy diagnosis might be “frozen shoulder”; limited movement due to pain. • Functional Goals – Should reflect the therapist’s and/or physician’s description of what the patient/client is expected to achieve as a result of therapy and must include anticipated date of achievement for short-term and long-term goals. • Rehabilitation Potential – The therapist’s and/or physician’s expectation concerning the patient’s/client’s ability to meet the goals at initiation of treatment. Goals From PGBA Jurisdiction 11 Home Health “WRITING THERAPY GOALS”: “The Guide to Physical Therapist Practice identifies a ‘goal’ as a remediation of impairments and uses the term ‘outcomes’ for ‘minimization of functional limitation, optimization of health status, prevention of disability, and optimization of patient/client satisfaction. The Guide defines ‘function’ as ‘those activities identified by an individual as essential to support physical, social, and psychological well-being and to create a personal sense of meaningful living’. The American Physical Therapy Association recommends the following components: • Identification of the person • Description of the movement or activity • A connection of the movement/activity to a specific function • Specific conditions in which the activity will be performed • Factors for measuring the outcome • Time frame for achieving the goal
