Therapy Assessment Documentation: 3 Tips
The assessment in a therapy note is the why behind the treatment you provided during that visit. A great assessment will highlight the necessity for skilled therapy and identify areas that need to be addressed in future treatments.
Part of your assessment should include a summary of the patient’s ability or difficulties in performing a specific task. Relating the treatment back to a functional goal will make for an excellent assessment statement.
How to Write an Assessment
You don’t need to write a paragraph here, but you don’t want to be too brief and gloss over important aspects of your skilled assessment.
3 Tips to Concisely Write an Excellent Assessment
Comment on Improvements and/or Impairments
Making a statement on a patient’s improvement in strength, balance, or mobility is a good use of space in the assessment. It’s also good to acknowledge areas that need continued work. Here’s an example:
“The patient is now able to ascend a 4” step but requires the use of both hands for support.”
Identify Response to Treatment
We’ve all seen the phrase “patient tolerated treatment well.” You should cringe if this is all you see in the assessment section.
The response should include areas such as ability to change movement patterns or posture, physical changes or adaptations during treatment, stability, etc. Here’s an example:
“The patient demonstrated poor upward rotation of the scapula with right shoulder flexion. Tactile cues and manual support of the scapula decreased popping in the shoulder.”
States the Reason to Continue Therapy
The assessment is a good place to argue for the continued care of your patient. Identifying the current improvements, remaining impairments, and your focus for addressing these impairments will make a strong case for continued therapy.
“The patient demonstrates improved balance as noted with ability to stand on a single leg for 3 seconds. However, he continues to lose his footing while ambulating on uneven surfaces. Dynamic stability training on varying surfaces should aid in the patient’s ability to safely navigate different terrains.”
Become Better at Writing Assessments
Sometimes we can get in a ‘documentation rut.’ After a long day of seeing patients, it may feel like you’re lacking the creativity to jump into ‘writing mode’ to document the treatments you just spent all day performing.
If you see 13 patients in a day, you can easily spend 5 to 10 minutes for each note. Saving even just 5 minutes per patient will reduce your documentation time by over 1 hour a day.
The assessment templates we’ve created will provide you with the format inspiration that you need to craft well written assessments in record time.
Take a look at the 60+ assessment examples below that will save you mental fatigue, time, and also help you to craft well written assessments that reflect the skilled care that you provide.
See the template image below or click here.