Nothing leaves this device. Drafts (including free-text notes) are saved locally to your browser so they survive a reload. Do not type real names, initials, MRNs, DOBs, or phone numbers into any field, including free-text notes.
Home Health PT
Initial Evaluation
Evaluation documentation
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No patient identifiers are stored or transmitted. All data remains on this device.
Used only to identify a saved draft. Never enter real names, initials, or identifiers.
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Medical History
PMH & existing conditions
Select Relevant Diagnoses
Additional Diagnoses / Notes
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Recent Hospitalization
Acute hospital stay details
Was Patient Recently Hospitalized?
Hospital
Admission Reason
Rehab Hospital Stay?
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Caregiver Availability
Support system & assistance
Caregiver Present
Caregiver Relationship
Level of Assistance Provided
Notes
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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
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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)
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Lower Extremity Strength
General assessment & MMT grades
General LE Strength
MMT by Muscle Group
Muscle Group
Left
Right
Notes
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Home & Safety
Fall history, stairs, and equipment
Falls in Previous 12 Months
Stairs in Home
Durable Medical Equipment Available
Notes
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Functional Mobility
Bed mobility & transfer assessment
Notes
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Cranial Nerve Testing
CN I–XII screening
Notes
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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
Patient is independent — add independence statement Includes: independent with all mobility, ADLs, and HEP; no caregiver assistance required
Skilled Justification Builder
Pattern: "Skilled intervention required due to X impairment interfering with Y functional task demonstrated by Z observation."
Impairment (X)
Functional task (Y)
Observation (Z)
Additional Clinical Notes
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Interdisciplinary Coordination
Team communication (Medicare home health requirement)
Coordinated with
Topic(s)
Coordination notes (optional)
Home Health PT
Evaluation Note
Home Health PT
Routine Visit Note
Used only to identify a saved draft. Never enter real names, initials, or identifiers.
⚠️
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
Neuro Screen
Timed Up and Go (TUG)
—
TUG Risk
Enter time to see fall risk interpretation.
30-Second Sit to Stand (30s STS)
Assistive Device
Ambulation Distance
Gait Quality
MMT — Manual Muscle Testing
Muscle group
Side
Grade
ROM
Therapeutic Exercise
Verbal Cues Provided
Tactile Cues Provided
Cue Notes — verbal/tactile specifics
Dyspnea
Session Vitals
%
bpm
Interventions Performed
Additional Notes
A
Assessment
Progress
Skilled Care Justification
Skilled Justification Builder
Pattern: "Skilled intervention required due to X impairment interfering with Y functional task demonstrated by Z observation."
Impairment (X)
Functional task (Y)
Observation (Z)
Rehab Potential
Additional Notes
P
Plan
Frequency
Next Session Focus
Discharge Status
Additional Notes
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Interdisciplinary Coordination
Team communication (Medicare home health requirement)
Coordinated with
Topic(s)
Coordination notes (optional)
Home Health PT
PTA Visit Note
PTA SCOPE REMINDER
A PTA carries out the plan of care established by the supervising PT. You may progress/modify within the POC but cannot evaluate, re-evaluate, revise the POC, or discharge. If the patient's status requires a POC change, document and notify the supervising PT rather than altering the POC in this note.
Used only to identify a saved draft. Never enter real names, initials, or identifiers.
⚠️
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
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Therapeutic Exercises
Exercises performed with dosage
Verbal Cues — Performance / Form
Tactile Cues
Cue Notes — verbal/tactile specifics
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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
⚠️
Within-POC Modification
Progression/regression within the POC — not a POC revision
Modification within POC
Explanation
Describe progression/regression within the POC (e.g., added resistance, reduced reps, adjusted cueing). If the POC itself needs revision, notify the supervising PT — do not revise here.
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Supervising PT Notification
Required if patient status, safety, or POC need change
Notified supervising PT
Reason / topic discussed
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Brief Assessment
Objective data/response within PTA scope — no evaluation or POC revision
Assessment
PTA scope: describe patient response, objective performance, and tolerance. Avoid evaluative/prognostic statements (e.g., "demonstrates good rehab potential") and avoid changing the POC.
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Interdisciplinary Coordination
Team communication (Medicare home health requirement)
PT Communication
Coordinated with
Topic(s)
Coordination notes (optional)
Home Health PT
PTA Visit Note
Home Health PT
Discharge Evaluation
End-of-episode documentation
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No patient identifiers are stored or transmitted. All data remains on this device.
Used only to identify a saved draft. Never enter real names, initials, or identifiers.
📅
Episode Summary
Start of care to end of care
Total Visits Completed
🏁
Reason for Discharge
Primary reason ending skilled PT
Notes
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Discharge Disposition
Where patient is being discharged to
🎯
Goal Status
Outcome for each goal from plan of care
Common Goals — Tap to Fill Input
Goal Description
Status
Goals Recorded
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Pain at Discharge
Current pain & comparison to initial
Current Pain (0–10)
Pain Location
Comparison to Initial Evaluation
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Functional Outcome Measures
Discharge vs initial
Timed Up and Go (TUG) at Discharge
—
TUG Risk
Enter time to see fall risk interpretation.
Initial TUG (optional, for comparison)
30-Second Sit to Stand at Discharge
Initial STS (optional, for comparison)
Assistive Device Used
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LE Strength at Discharge
General & MMT grades
General LE Strength
MMT by Muscle Group
Muscle Group
Left
Right
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Functional Mobility at Discharge
Final assist levels
⚠️
Safety During Episode
Falls and incidents during home health
Falls During Episode
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Recommendations
HEP, follow-up, DME
Home Exercise Program
Follow-Up
DME Recommendations
Summary & Additional Notes
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Interdisciplinary Coordination
D/C communication (Medicare home health requirement)
Coordinated with
Topic(s)
Coordination notes (optional)
Home Health PT
Discharge Note
Home Health PT
SOAP Note
Home Health PT
Homebound Statement
Medicare-compliant homebound justification
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Do not enter real names, MRNs, or DOBs. Use age, diagnosis, and functional descriptors only.
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Session Info
Label and date for draft tracking
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Primary Reason(s) for Homebound Status
Select all that apply
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Functional Limits
Measurable deficits for the statement
Max safe ambulation distance
Symptoms with minimal exertion
Recovery time needed after exertion
Assistive device
Level of assistance required
Additional safety risks
Functional notes (optional)
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Home Environment & Leaving-Home Impact
Barriers to leaving the home
Stairs at entrance
Leaving home exacerbates
Transport / logistics barriers
Home environment notes (optional)
➕
Additional Clinical Context
Diagnoses, medications, recent events
Recent hospitalization / surgery
Supplemental oxygen
Other contributing factors
Additional notes (optional)
Home Health PT
Homebound Statement
Home Health PT
Authorization Request
Medicare-defensible justification for skilled PT
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Do not enter real names, MRNs, or DOBs. Use age, diagnosis, and functional descriptors only.