Physical Therapy Initial Evaluation Checklist
Comprehensive physical therapy initial evaluation including subjective history, objective examination, assessment, and treatment planning.
- Industry: Healthcare
- Frequency: Initial evaluation
- Estimated Time: 45-60 minutes
- Role: Physical Therapist
- Total Items: 31
- Compliance: APTA Guide to Practice, CMS Documentation Requirements, State Practice Act
Subjective History
Patient-reported information
- Chief complaint documented?
- History of present condition?
- Prior level of function documented?
- Patient goals identified?
- Relevant medical history documented?
Objective Examination
Clinical findings
- Range of motion assessed?
- Strength assessed?
- Balance assessed?
- Gait/mobility assessed?
- Functional tests completed?
Assessment
Clinical impression
- Clinical impression documented?
- Rehabilitation potential assessed?
- Barriers to progress identified?
Plan of Care
Treatment planning
- Measurable goals established?
- Frequency and duration specified?
- Interventions planned?
- Discharge criteria identified?
Pre-Assessment Information
Initial assessment documentation and patient/facility identification
- Assessor Name / Credentials
- Assessment Date
- Department / Unit
- Assessment Type (Routine/Annual/Complaint)
- Previous assessment findings reviewed?
Infection Prevention & Control
Verify infection control practices per CDC and Joint Commission standards
- Hand hygiene compliance observed?
- Appropriate PPE available and properly used?
- Isolation precautions properly implemented?
- Sharps containers available and not overfilled?
- High-touch surfaces properly disinfected?
Patient Safety & Identification
Verify patient safety protocols and identification procedures
- Two patient identifiers used before procedures?
- Fall risk assessment completed?
- Call light within patient reach?
- Bed in lowest position with brakes locked?
Related Healthcare Checklists
- Occupational Therapy Initial Evaluation Checklist
- Speech-Language Pathology Evaluation Checklist
- Social Work Assessment Checklist
- Dietary/Nutrition Screening Assessment Checklist
- Respiratory Therapy Assessment Checklist
- Chaplain/Spiritual Care Assessment Checklist
- Wound Care Assessment & Documentation Checklist
- Pre-Operative Nursing Assessment Checklist