A physical therapy evaluation is the synthesis of all the information you gather during a physical therapy examination. Oftentimes, Physical Therapy “evaluation” and “examination” are used interchangeably when referring to the patient’s first encounter with a Physical Therapist. In this article, we’ll discuss the components necessary to write a physical therapy evaluation as well as the basic structure of an examination. You can also download a physical therapy evaluation example to use as a template.
Physical Therapy Evaluation 101
If you’re a student PT or a new grad Physical Therapist, you’re probably familiar with a physical therapy evaluation. But let’s make sure you really know the why and the what before we get into the how.
Evaluations. The Why:
Physical Therapy evaluations are generally the first encounter you have with a patient and sets the expectations for the rest of the plan of care, or the time you anticipate seeing the patient. The evaluation documentation you create following the patient’s initial evaluation becomes a part of the patient’s medical records, along with the notes from every subsequent visit.
These records are important because other therapists, physicians, and even the patient’s health insurance company may reference your notes in the future. The patient may also request to see their therapy notes, so writing accurate and thorough documentation is important.
Evaluations. The What:
Let’s break it down into two parts: clinical examination and the written therapy evaluation.
Clinical Examination: Most clinics will set aside 45 to 60 minutes for the initial evaluation. During the evaluation, you’ll cover a lot of information, which may include:
- Patient’s Medical History
- Systems Review
- Tests & Measures
- Posture & Gait Analysis
- Range of Motion & Muscle Strength Testing
- Special Tests
- Home Exercise Prescription
- Goal Setting
- Treatment Recommendations
For an in depth look at how to structure your PT eval, check out the Therapy Evaluation Templates
Written Evaluation: After the clinical evaluation is completed, you’ll need to finalize the encounter with documentation. This involves typing up your report that includes all your findings as well as your professional assessment of the patient and why they need therapy. The written evaluation may take anywhere from 15 to 45 minutes to complete after you’re done with your visit, depending on how much information you were able to document during the visit and whether or not your system is easy to use.
The rest of this article will focus on writing your evaluation and using physical therapy evaluation template forms and therapy evaluation examples to help you write better notes in less time.
Physical Therapy Evaluation CPT Code
In 2017 the CPT codes for therapy evaluations changed to reflect different tiers or evaluation levels.
Based on factors such as patient history, examination, clinical presentation, and clinical decision making skills, you can select a low, moderate, or high level evaluation CPT code.
Physical Therapy Evaluation CPT Codes
97161 – Low Complexity
97162 – Moderate Complexity
97163- High Complexity
97164 – PT Re-Evaluation
Occupational Therapy Evaluation CPT Codes
97165 – Low Complexity
97166 – Moderate Complexity
97167 – High Complexity
97168 – OT Re-Evaluation
Choosing an evaluation CPT code is not simply a matter of how much time you spent with the patient. While time spent with the patient is a contributing factor (20, 30, 45 minutes for low, moderate, high complexity), it is not a requirement or the only factor to consider.
Selecting an Evaluation Complexity Level
As you can see in the chart below, selection of a low, moderate, or high level evaluation CPT code will depend on these key factors:
- Clinical Presentation
- Clinical Decision Making Skills
As of 2020, CMS has not released a tiered reimbursement based on the tiered evaluations. PT evaluations are reimbursed at the same level as of now. It’s expected they will make changes with this data, but nothing moves fast with CMS.
While it’s important to accurately document your findings and to perform a thorough evaluation, there is not a ‘penalty’ for selecting a low complexity eval, moderate or high complexity eval. They’ve tried to make the selection process as objective as possible, but there will be overlap in opinion as to what classifies as low, moderate, or high. Do your best and just select an eval code and move on. If we spend 5 minutes mulling over the complexity of the eval, we can miss the forest for the trees.
Physical Therapy Examination
Before we can even begin writing a therapy evaluation, we need to get an idea of what the exam flow will look like.
Before the Exam Starts
Before you even see the patient, there’s a good chance you’ll have the opportunity to look over the patient intake form. A good patient intake form will give you a concise roadmap that should help identify some of the major issues, which may lead you to ask further questions during the actual examination.
Your first impressions with the patient can impact the rest of the evaluation and treatment session. In the Evaluation Templates, I share my exact formula for putting patients at ease and the wording I use to help my evaluations flow as smoothly as possible. While you shouldn’t write out every question you plan on asking the patient, you should be able to talk conversationally and lead the examination as you try to find the best treatment plan for the patient.
One of the first elements covered in a physical therapy evaluation is the patient’s medical history. As the physical therapist, be very mindful how you present the question asking about the patient’s medical history. Be careful what you ask for, otherwise you might feel like you’re spiraling down a path of information that may not be relevant for you at this very moment. Be direct and ask the patient about pertinent medical history and the events that led up to the reason they’re seeking physical therapy today.
As you start to gather information from the patient during your exam, you’ll be able to narrow in with specific questions to identify how various body systems are involved. Your critical thinking skills will come into play here as you think through various systems from neuromuscular to cardiovascular and integumentary. Your understanding of how these body systems respond based on the symptoms and presentation of your patient will be important to think through as you develop a physical therapy diagnosis and plan for treatment.
Physical Therapy Tests & Measures
During the examination, you’ll use a variety of special tests and measurement tools to gather relevant information about the patient. From ROM (range of motion) to MMT (manual muscle testing) and neuro screening tests, you’ll tailor your exam based on the individual patient. It’s important to also realize that a thorough exam doesn’t mean performing every special test available. Your ability to efficiently gather information during the time you have with the patient will improve with time.
Presentation of Findings
As you progress through the examination, you will start to develop an understanding of key factors contributing to the patient’s pain, discomfort, or overall functional limitations. It can be helpful to briefly summarize your initial impression with the patient to share a prognosis and plan for their care. As you present your findings, be mindful that people respond differently, even if it’s a routine injury like an ankle sprain or a major surgery like a total joint replacement.
Part of the initial physical therapy visit may include treatment intervention performed during the session. It’s common for a physical therapist to identify specific movements and helpful exercises based on the patient’s clinical findings, so providing a list of home exercises is commonly done at the end of the session.
The physical therapist will also use this time to set an expectation of visit frequency and recommended treatment which may correspond to the general recommendations provided on the physician’s script for PT.
Writing a Physical Therapy Evaluation
After the physical therapy initial evaluation visit is finished, you’ll need to write up the written evaluation.
In almost every clinic I’ve worked in, the electronic medical record (EMR) allowed me to type and document during the visit. This gave me a head start in completing the evaluation, saving valuable time afterwards.
Having a framework for your exam will help you to become more efficient as you document your evaluation findings on the computer while you’re with the patient.
Completing 100% of the evaluation during the patient visit usually doesn’t happen.
You can expect to spend anywhere from 15 to 45 minutes typing an evaluation after the visit is finished.
Key Components of a Physical Therapy Evaluation
While the overall structure of a physical therapy evaluation does follow a broad SOAP note format, you’ll cover a lot more detail in this initial note than in most follow up notes or daily notes.
Subjective / Chief Complaint / Past Medical History
One of the first sections of any written evaluation will allow the therapist to document relevant information about the patient and why they are seeking therapy in the first place. While some EMRs rely heavily on checkboxes and drop down option, you’re likely to see a free-text section where you can write out a patient subjective and past medical history.
Here’s an example of one:
The patient is a 62 year old female who presents with complaints of right knee pain s/p TKA performed on 11/29/18. The patient reports having knee pain for years before she consulted with an ortho surgeon in August of 2018. An Xray revealed severe arthritis and the patient elected to undergo total knee replacement in November of 2018. The patient reports the surgery was performed with no issue. She was released home after a one night stay at the hospital. The patient lives with family who is able to assist with driving her to appointments until cleared by physician to drive. The patient’s goals are to return to working as a college administrator this spring, and to ‘walk without a walker or cane as soon as possible.”
Objective Testing / Special Tests / Relevant Data
During the initial evaluation, you’ll gather a lot of information that will serve as a ‘baseline’ to compare against as you progress the patient towards their goals. While you may not be able to get to every test during this initial treatment, you will still document your findings along with any other relevant data from outcome measures or forms the patient completed in their initial paperwork.
Interested in learning more about special tests? Visit our Special Tests page.
Therapy Assessment, Diagnosis, Prognosis, & Goals
The next section of the written evaluation will cover the overall assessment, diagnosis, and prognosis as well as goals. This section specifically answers the question, “why does this person need physical therapy right now.” This section answers that question and uses the data gathered through the examination to put the finishing touches on the evaluation.
Plan of Care
The evaluation will generally finish with a reference to a plan of care. This outlines the frequency of visits you recommend as well as the potential treatment options you expect to provide during the entire plan of care. Many states as well as insurance companies require the physician to sign this section in order to approve the PTs recommended treatment.
Want a Full Evaluation Example?
Take a look at my therapy notes with a full text evaluation and sample assessments that will help you save 30 to 60 minutes a day.