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Physical therapy report

Physical therapy report 2026

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The document is a Physical Therapy Outpatient Discharge Report that includes patient information, treatment details, and assessments of progress. It outlines the patient's diagnosis, treatment dates, sessions attended, initial symptoms, administered treatments, pain rates, strength, range of motion (ROM), gait, balance/coordination, achievement of goals, recommended home program, prognosis, and signatures from the physical therapist and assistant.

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Click ‘Get Form’ to open the physical therapy report in the editor.
Begin by entering the patient's name and date at the top of the form. This information is crucial for identifying the report.
Fill in the physician's name and diagnosis fields. Accurate details here ensure proper communication among healthcare providers.
Document treatment dates, sessions attended, and any missed sessions. This section tracks patient progress and adherence to therapy.
In the symptomatology section, describe any issues identified during the initial visit. Be thorough to provide a clear picture of the patient's condition.
Record treatment administered, including pain rate, strength, range of motion (ROM), gait, and balance/coordination assessments.
Evaluate achievement of goals and recommend a home program tailored to the patient's needs.
Finally, ensure both physical therapist and assistant sign at the bottom of the form for validation.

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Versions	Form popularity	Fillable & printable
2014	4 Satisfied (26 Votes)

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What does a PT assessment look like?

Before Your Visit Make a list of any questions you have and want to ask your physical therapist. Write down any symptoms youve been having and for how long. Write down key information about your medical history, even if it seems unrelated. Ask a family member or trusted friend to go with you to your appointment.

What does a PT evaluation consist of?

A complete PT evaluation starts with a clinical examination comprising the patient history, systems review, and objective data collection. Then, the PT communicates their findings in an evaluation followed by a prescribed plan of care (POC).

How to write a PT progress note?

To simplify, your progress note should answer these questions; Who is the patient? What is the reporting period? What is the chief complaint? Have we made progress towards our goals? What subjective and objective findings tell us we have made progress?

How to write a good review for a physical therapist?

Great attitude and a truly caring physical therapist! She has great focus and technique. She is competent and well trained. I could not have healed as well as I have without her hard work in guidance. She excelled at maintaining the PTI facility throughout the continuing COVID-19 pandemic.

How do I prepare for a PT evaluation?

For most people, the initial evaluation will last up to 60 minutes and between 30-60 minutes for follow-up visits. The duration of your care will also depend on your specific needs. At your initial evaluation, your therapist will discuss their assessment and clarify any questions you may have.

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