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This document is used for evaluating and planning physical therapy treatment for patients, including diagnosis, treatment frequency, modalities, exercises, education on body mechanics, and appointment
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How to fill out Physical Therapy Evaluation and Treatment

01
Gather patient information: Collect personal details, medical history, and referral information.
02
Conduct an initial assessment: Evaluate the patient's condition through physical examination and tests.
03
Set goals: Collaborate with the patient to establish realistic and measurable treatment goals.
04
Develop a treatment plan: Outline specific interventions, frequency, and duration of therapy.
05
Document findings: Record all assessment results, goals, and treatment plans in the evaluation form.
06
Review and adjust: Continuously monitor the patient's progress and make necessary adjustments to the treatment plan.

Who needs Physical Therapy Evaluation and Treatment?

01
Individuals recovering from surgery or injury.
02
Patients with chronic pain disorders.
03
People with movement difficulties due to neurological conditions.
04
Athletes looking to improve performance or recover from injuries.
05
Individuals with balance or coordination issues.
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Physical therapy evaluations require the following components in selecting the correct evaluation level — History, Examination, Clinical Presentation, and Clinical Decision Making.
97161: Characteristics of a Low Complexity PT Evaluation The PT completes an examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions.
Key components of an evaluation include patient history, clinical examination, functional limitation assessment, and a tailored treatment plan.
Clinical decision-making (CDM) is a contextual, continuous and evolving process where data is gathered, interpreted and evaluated to select an evidence-based action.
(1) Physical therapy evaluation includes the administration, interpretation, and evaluation of tests and measurements of bodily functions and structures; the development of a plan of treatment; consultative, educational, and other advisory services; and instruction and supervision of supportive personnel.
Physical therapy, or physiotherapy, is treatment that helps you improve how your body performs physical movements. It can be part of a generalized pain management plan or a specific treatment for an injury or health condition. It's common to need physical therapy after many types of surgery, too.
A physical therapy evaluation consists of a thorough assessment of your medical history, current condition, and physical abilities to identify areas of pain, weakness, or dysfunction. This includes a patient interview, range of motion and strength testing, and a functional assessment of daily activities.

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Physical Therapy Evaluation and Treatment is a comprehensive process where a licensed physical therapist assesses a patient's physical condition and designs a personalized treatment plan to address mobility issues, pain management, rehabilitation, and overall physical health.
Licensed physical therapists who provide evaluation and treatment services to patients are required to file Physical Therapy Evaluation and Treatment documents as part of documenting their clinical assessments and treatment plans.
To fill out Physical Therapy Evaluation and Treatment forms, the therapist must gather patient information, assess the patient’s physical condition, document findings, outline treatment goals, and specify the treatment plan along with any necessary follow-up care.
The purpose of Physical Therapy Evaluation and Treatment is to evaluate a patient's functional capacity and pain levels, identify impairments, set rehabilitation goals, and implement a tailored treatment strategy aimed at improving the patient's quality of life.
The information that must be reported includes patient demographics, medical history, assessment findings, diagnosis, treatment goals, planned interventions, and any progress made during treatment sessions.
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