Question

A PT who performs a re-evaluation shall document:

1. the pt's ___________________
2. assessment of the pt's ____________
3. the pt's current functional status
4. objective data from ______________, if collected
5. rationale for _____________________
6. any change in the POC

Answer 1

In physical therapy re-evaluation, a PT documents observations, outcomes, the patient's current functional status, objective data from tests, rationale for further intervention, and any changes in the Plan of Care.

Step-by-step explanation:

A physical therapist (PT) who performs a re-evaluation shall document several key components to assess and progress a patient's treatment plan. These components include:

• The patient's observations, which capture subjective reports of symptoms and progress.
• Assessment of the patient's outcomes, including measurable changes in function since the last evaluation.
• The patient's current functional status, providing a snapshot of their abilities at the time of re-evaluation.
• Objective data from tests and measures, if collected, which provide concrete data points to guide clinical decision-making.
• The rationale for further intervention, explaining why continued PT is necessary based on the data.
• Any change in the Plan of Care (POC), which adapts the treatment to the patient's current needs and goals.

These components are critical to ensuring high-quality, patient-centered care and to justify the necessity and effectiveness of ongoing physical therapy services.