Question

A patient fails to attain established physical therapy goals within the number of visits initially set by the physical therapist. The patient has made substantial progress in therapy, however has plateaued over the last 4 sessions. The most appropriate action for the physical therapist is?

A. Request additional visits from the referring physician
B. Document a progress note that updates the patient's current status
C. Talk to the patient regarding their compliance
D. Discharge the patient from physical therapy with a home exercise program

Answer 1

The physical therapist should document a progress note updating the patient's status, highlighting both progress and any recent plateau. This serves as a basis for deciding further steps, which may include requesting additional visits or discussing compliance and planning a home exercise program.

Step-by-step explanation:

When a patient does not achieve the established physical therapy goals within the scheduled number of visits, the most appropriate action for the physical therapist (PT) would be to document a progress note that updates the patient's current status. This note should detail the progress that has been made as well as the plateau observed over the last 4 sessions. Furthermore, the therapist may request additional visits from the referring physician to continue working towards the goals, discuss the therapy plan and compliance with the patient, or possibly discharge the patient with a home exercise program if deemed appropriate. However, updated documentation is an essential step in any of these scenarios, as it ensures clear communication with both the patient and other healthcare providers involved in the patient's care.