Let’s delve into the nitty-gritty of documentation! In this article, we’ll cover how to write evaluation reports for adult rehab-therapy patients.
* Your funding source may have its own guidelines for documentation. Learn them!
What we’ll cover
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1) Why Write a Great Report?
Writing Evals can be time-consuming, not exactly rewarding, yet pretty darn important to get right for many reasons.
1) To justify the skilled therapy services you recommend—or don’t recommend—and will bill for
2) To get your agency paid
3) To gather detailed and specific data to assess patient progress over time
4) To have a clear assessment of your patient for other stakeholders to read. Stakeholders include patients, their families, plus any medical providers down the line from you, including COTAs or PTAs that follow your Plan of Care.
2) 7 Elements of an Evaluation Report
This includes the Reason for the Referral and Tests.
Reason for Referral
This is subjective information that you will gather by interviewing the patient and/or reviewing medical records.
- Presenting illness/condition. Why does it relate to the medical and treatment diagnoses? Why does the patient need therapy?
- Date of onset of presenting illness/condition. (e.g., date of CVA, date of fall, date of physician referral)
- Medical history
- Surgical history
- Clinical Tests (CT, X-ray, MBSS, etc)
- Social history
- Living environment
- Previous level of functioning (PLOF). As the name implies, keep it functional! Include relevant areas. For example, regular diet with thin liquids, normal speech, walked with a cane.
The current level of functioning (under Evaluation) is what the patient can no longer do since the presenting illness/condition. How much more assistance do they need? Are they avoiding anything due to the illness/condition?
Your goals will bridge the gap between the patient’s PLOF and current level of functioning.
This is the objective data that you gather through standardized tests, scales, etc.
- Include the full test name and version (when applicable)
- Include patient’s scores
- Include severity level
- Include normal score comparison
Areas to test may include language, feeding and swallowing, cognition, manual muscle testing, pain, aerobic capacity, endurance, cranial and peripheral nerves, adaptive devices, ADLs, gait, balance, etc.
This is your summary of the patient’s current level of functioning (including strengths and weaknesses) based upon the reason for referral and tests results.
Include whether or not you recommend treatment.
Include relevant medical diagnoses and treatment diagnoses.
Medical diagnoses are made by a physician (e.g., CVA or Parkinson’s Disease).
Treatment diagnoses can be made by the therapist based on the evaluation results. For example: dysphagia, oropharyngeal phase. Or semantic paraphasias.
You may choose to describe the diagnoses in layman’s terms: “a swallowing disorder characterized by…”. Or give examples: “The patient said ‘grape’ instead of ‘tomato'”.
The prognosis is based on your professional judgment on a scale of excellent, good, fair, to poor.
How to Determine Prognosis
1) The patient’s previous level of functioning
2) Current level of functioning
3) Amount of family support (i.e. family can help with homework, can monitor health concerns, etc.)
4) Amount of motivation
5) Insight into deficits
6) Any comorbidities and the severity of each
Your employer will likely give you guidance about how to determine a prognosis. For example, its documentation system may include descriptions for each prognosis level.
Examples of Prognosis
Excellent Prognosis: Patient will likely make a full recovery due to excellent insight and motivation, mild deficits, high previous levels of functioning, and excellent family support
Poor Prognosis: Patient may make some progress with a few goals due to poor insight of deficits, ongoing medical issues, the severity of deficits, and minimal support at home.
5. Plan of Care
The short-term and long-term goals you write for the patient, based on the evaluation results.
Many insurance companies require that you add a time frame (when each goal will be reached).
6. Therapeutic Intervention for Plan of Care
Document what specific therapeutic interventions the treating therapist will provide to reach those goals (for example LSVT Big, ADL training, diet modification, etc).
Be clear why a skilled SLP, PT, or OT is needed for these interventions. If the goals can be reached with only a home exercise program, payers may deny payment.
Include your recommendation for the duration and frequency of therapy visits.
7. Discharge Planning
Include where you plan (or hope) the patient will discharge to. Usually, this will be the patient’s home.
Include how much assistance you plan the patient will need upon discharge.
For Example: Plan is to discharge to home under the supervision of a caregiver. Or: Plan is to discharge to an assisted living facility (family is working with social worker to identify suitable facilities).
A quick reminder about the “look” of a report:
Every company’s evaluation report looks different.
Payers, including Medicare and insurance companies, don’t care what order you write the information in your report—as long as you include it all.
Be sure to know what information each payer requires.
The following examples don’t follow the order of the “7 Elements” described above. But you’ll see that all of the major elements are in there.
3. Example Speech Therapy Evaluation Report
HOME HEALTH SETTING
Date of Evaluation: 04/19/21
Subjective Information: Mrs. Jung is a 65-year-old female seen at Local Hospital from 04/10/21 to 04/17/21. Mrs. Jung’s daughter, Mei, called 911 after noticing that Mrs. Jung had slurred speech and “wasn’t making any sense.” CT scan performed on 04/10/21 found that Mrs. Jung experienced a L frontotemporal infarct. She received ST at Local Hospital from 4/11/21 to 4/17/21 for dysphagia treatment. A modified barium swallowing study completed during hospitalization found aspiration on cup-sips of thin liquids and moderate pharyngeal residue given soft & bite-sized textures (SLP awaiting full results from Local Hospital medical records). A minced & moist diet with slightly thick liquids was recommended at that time. Mrs. Jung is now referred to ST for continued swallowing concerns to determine risk for aspiration. Mrs. Jung’s medical history is significant for hypertension, hyperlipidemia, and asthma. Surgical history is significant for thyroid removal in ~1998.
Previous Level of Functioning: Patient was previously independently on a regular diet with thin liquids.
Objective Data: The Mann Assessment for Swallowing Ability (MASA) was administered. Mrs. Jung received a 165/200 indicating moderate dysphagia and a mild risk for aspiration given minced & moist textures and mildly thick liquids. Oral periphery examination was completed and significant for moderate bilateral lingual weakness and reduced range of motion, moderately reduced R labial strength and range of motion, and moderately reduced buccal range of motion.
Evaluation: Mrs. Jung demonstrated moderate oropharyngeal dysphagia
characterized by reduced mastication, moderate oral residual post swallows, delayed swallows (~2 seconds), reduced pharyngeal elevation, and seemingly protective coughing post swallows given soft & bite-sized textures and thin liquids. She independently cleared some oral residue using lingual sweep technique. Oral residue reduced to minimal given minced & moist textures. Coughing was eliminated given slightly thick liquids. Mrs. Jung reported bolus sensation with soft & bite-sized textures.
Prognosis: Good, given previous success in ST, insight into deficits, high motivation, and stimulability for swallowing strengthening exercises (Mendelsohn Maneuver).
Plan of care (Goals): Long-Term Goal is to safely consume PLOF diet (regular/thin) using safe swallowing strategies IND in 2 months. Short-Term Goals include use of safe swallowing strategies in 100% of opportunities given minimal verbal cues and completion of swallowing strengthening exercises in 4 weeks.
Plan of care (Therapeutic Interventions): Recommend continuation of minced & moist diet and slightly thick liquids at this time to reduce risk for aspiration. Recommend ST 2w6 for skilled dysphagia treatment to provide training in the use of swallowing strengthening exercises and safe swallowing strategies to reduce risk for aspiration and increase Mrs. Jung’s abilities to safely consume the least restrictive diet.
Discharge Plan: Plan is to remain home, possible follow-up modified barium swallowing study within the next month.
Signature & Credentials: Audrey Brown, M.A., CCC-SLP
4. Example Physical Therapy Evaluation Report
ASSISTED LIVING FACILITY
Date of Evaluation: 5/10/2021
Significant History/Precautions: 85 yo with Alzheimer’s dementia, rectal prolapse. 4/22/21-5/1/21 hospital stay for sepsis. Director of Assisted Living Facility and pt’s husband believe pt should be at SNF. They have 24/7 hired caregiver now to assist with mobility and monitor prolapsed rectum- rectum was bleeding this morning. They went to ED on 5/1/2021 for bleeding rectum, f/u scheduled on 5/12/2021 with colorectal specialist. Husband reports pt lost ~10 lbs at hospital, much weaker now. Pt found on the floor 5x in March/April, no injuries and none were witnessed.
Previous Level of Function: Resides in memory care unit. Requires assist with dressing, bathing, medication management, meals, walk pt to meals, check in on her every 2 hours. On-call with call button for more assistance as needed. Ambulating without assistive device mod I/supervision.
Evaluation: PAIN (0-10): Minor but constant pain in her rectum. Does not give Visual Analog Scale (VAS) number, Pain Assessment in Advanced Dementia Scale (PAINAD) 1/10, VITALS: SpO2 97% HR 56. MENTAL STATUS: Alert, oriented to self. Confused from dementia, poor memory, does not answer questions.
Physical Evaluation: EDEMA: Min L ankle edema, INTEGUMENT: No sores. Prolapsed rectum which nurse/husband occasionally needs to push in- went to ED for this issue although ED concluded they could do nothing, ROM / TONE: B UE and LE WFL. STRENGTH: Unable to complete MMT due to pt confusion. >3/5 in B LE, antigravity and holds min resistance. BALANCE / COORDINATION: Seated good. Standing poor+, does not use assistive device but has reduced stability, stumbles on multiple occasions and has hx of falls. FTBS 2/4, unable to tandem or SLS. BED MOBILITY: Supervision supine <> sit and rolling. TRANSFERS: SBA sit <> stand from dining chair, arm chair, bed, toilet using grab bars. Rises on her own but sometimes appears unstable upon standing. Min A to walk in shower using grab bars. GAIT: Amb through facility 2 x 200′ with CGA/min A using no assistive device. Pt stumbled on 2 occasions but Physical Therapist able to catch pt and prevent fall. Has never used front-wheel walker; she declines use during assessment and leaves it behind. ENDURANCE: Reduced, does not fatigue this session but reportedly used to walk many times a day. STANDARDIZED TESTING: Functional Independence Measure (FIM) 59; MACH 10 Fall Risk Assessment Tool 8.
Assessment – Pt is an 85 year old female referred to home health Physical Therapy following hospital stay from 4/22/21-5/1/19/21 at Community Hospital for sepsis and acute metabolic encephalopathy. Pt has hx of rectal prolapse, asthma, HLD, Alzheimer’s dementia. She went to ED on 5/1/21 for rectal prolapse and bleeding and will follow up with colo-rectal specialist on 5/13/21 as symptoms continue. Resides in memory care unit with assistance for ADLs, med management, mobility; hired 24/7 caregiver currently due to declined function and mental status since return home from hospital. Supportive husband lives in own home but visits daily. At baseline, pt walks with supervision A without an assistive device and is mod I with mobility in her room. Upon evaluation, pt is confused and unsafe with transfers, requiring SBA. She requires CGA with ambulation and stumbles with transfers and walking. Family reports weight loss, weakness, decreased mobility.
Patient Strengths: Great facility and CG support, baseline of walking without assistive device
Potential Barriers to Progress: Weight loss, dementia limiting carryover of teaching
Home Safety Instructions: Daily walks with caregiver, supine exercises and sit to stands for strengthening, FALL PREVENTION SPECIFICS: CGA for indoor mobility, supervision sit <> stands, durable medical equipment
Discharge Outcomes (Goals):
1. CG training to facilitate HEP (home exercise program) for progressing LE strength and balance
2. Mod I with transfers in room to prepare for ADLs and toileting
3. SBA community distance ambulation using LRAD (least restrictive assistive device)
Therapeutic Interventions for Plan of Care:
OASIS, medication review
Assess ROM, strength, balance, transfers mobility
Discuss level of care and concerns about pt with assisted living director, husband, CG
Exercises with CG training: bridges, hip abd/add, SLR, sit <> stands, x 10 ea with cues for proper technique
Discharge Plan: Discharge home IND.
Signature & Credentials: Manuel Hernandez, DPT
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