December 16th, 2016
In terms of physical therapy, at a minimum, physical therapy evaluations should include the following:
- Clinical decision making
- Development of plan of care
- Body regions: head, neck, back, lower extremities, upper extremities, and trunk
- Body systems: musculoskeletal, neuromuscular, cardiovascular pulmonary, and integumentary.
- A review of body systems includes the following:
- For musculoskeletal: the assessment of gross symmetry, gross range of motion, gross strength, height, and weight.
- For neuromuscular: a general assessment of gross coordinated movement (e.g., balance, gait, locomotion, transfers, and transitions) and motor function (motor control and motor learning)
- For cardiovascular pulmonary: the assessment of heart rate, respiratory rate, blood pressure, and edema
- For integumentary: the assessment of pliability (texture), presence of scar formation, skin color, and skin integrity
- Personal factors: Factors that include sex, age, coping styles, social background, education, progression, past and current experience, overall behavior pattern, character, and other factors that influence how disability is experienced by the individual. Personal factors that exist but do not impact the physical therapy plan of care are not to be considered, when selecting a level of service.