Home Health PT

PT Documentation

Select note type to begin
🔒
No patient identifiers are stored or transmitted. All data remains on this device.
📋
Initial Evaluation
PMH, hospitalization history, TUG, 30s STS, LE strength, functional mobility, plan of care setup.
EVAL
📝
Routine Visit Note
SOAP format — subjective, objective findings, interventions, assessment, and plan.
SOAP
⚙️
PTA Visit Note
Skilled interventions, exercises, objective measurements, patient response, and plan variations.
PTA
Home Health PT

Initial Evaluation

Evaluation documentation
🔒
No patient identifiers are stored or transmitted. All data remains on this device.
🩺
Medical History
PMH & existing conditions
Select Relevant Diagnoses
Additional Diagnoses / Notes
🏥
Recent Hospitalization
Acute hospital stay details
Was Patient Recently Hospitalized?
👥
Caregiver Availability
Support system & assistance
Caregiver Present
Caregiver Relationship
Level of Assistance Provided
Notes
⚡
Pain & Vitals
Pain, oxygen, dyspnea, session vitals
Supplemental Oxygen
L/min via nasal cannula
Current Pain (0 = none, 10 = worst)
Pain Location
Pain Character
Aggravating Factors
Notes
Dyspnea
Session Vitals
%
bpm
📊
Functional Outcome Measures
TUG & 30-Second STS
Timed Up and Go (TUG)
—
TUG Risk
Enter time to see fall risk interpretation.
Assistive Device Used During TUG
30-Second Sit to Stand (30s STS)
—
vs Norm
Enter reps to see performance vs age-based norms.
Patient Age Range (for STS norms)
💪
Lower Extremity Strength
General assessment & MMT grades
General LE Strength
MMT by Muscle Group
Muscle GroupLeftRight
Notes
🏠
Home & Safety
Fall history, stairs, and equipment
Falls in Previous 12 Months
Stairs in Home
Durable Medical Equipment Available
Notes
🛏
Functional Mobility
Bed mobility & transfer assessment
Notes
🧠
Cranial Nerve Testing
CN I–XII screening
Notes
📋
Clinical Impressions
Goals, POC, and additional findings
Short-Term Goals (2–4 weeks)
Long-Term Goals (6–8 weeks)
Visit Frequency
Rehab Potential
PT Response Statement
Patient responds well to PT — add statement to note
Includes: functional assessment completed, appropriate candidate for PT
Additional Clinical Notes
Home Health PT

Evaluation Note

Home Health PT

Routine Visit Note

⚠️
Safety Check-In
Falls & medication changes since last visit
Falls Since Last Visit
Medication Changes
S
Subjective
Patient Reports
Pain Scale (0–10)
Pain Location
Participation
Additional Notes
O
Objective
Supplemental Oxygen
L/min via nasal cannula
Functional Mobility
Cranial Nerve Testing
Assistive Device
Ambulation Distance
Gait Quality
MMT — Manual Muscle Testing
ROM
Therapeutic Exercise
Dyspnea
Session Vitals
%
bpm
Interventions Performed
Additional Notes
A
Assessment
Progress
Skilled Care Justification
Rehab Potential
Additional Notes
P
Plan
Frequency
Next Session Focus
Discharge Status
Additional Notes
Home Health PT

PTA Visit Note

⚠️
Safety Check-In
Falls & medication changes since last visit
Falls Since Last Visit
Medication Changes
⚙️
Skilled Interventions
Specific description of treatment performed
Interventions Performed
Detailed Description
💪
Therapeutic Exercises
Exercises performed with dosage
📊
Objective Measurements
ROM, distance, validated scales
Range of Motion (ROM)
Distance Ambulated
Validated Functional Scales
❤️
Patient Response
Tolerance and response to treatment
Tolerance to Session
Response Notes
⚠️
Plan of Care Variation
Any deviations from planned treatment
Variation from POC
📋
Brief Assessment
Progress and clinical impression
Assessment
Home Health PT

PTA Visit Note

Home Health PT

SOAP Note