Quick Tips for Completing a Good Evaluation - Kristin B., Physical Therapist

Though evaluations differ from setting to setting and between different disciplines there are a few general rules that govern the completion of a good evaluation.

1. Ensure that a prescription or order is in place prior to completing an evaluation (if working in a state where this is required).
2. Complete a full chart review or review the medical history form provided by the patient to ascertain pertinent health history information.
3. Gather information regarding any precautions that may apply to the evaluation and treatment of the patient, for example weight bearing status or lifting restrictions.
4. Determine the patient’s prior level of function and personal goals for therapy as a starting point for what you may need to assess during the evaluation.
5. Once the evaluation is underway, be complete in your assessment. It is much easier to write goals and monitor progress along the way if initial measurements and functional levels are listed.
6. When deciding on frequency and duration consider the patient as an individual. Each patient will have different needs and you cannot predict the course of therapy based on the diagnosis only.
7. Consider the patient’s wants and needs when creating goals. The patient will be much more likely to participate fully if they feel like they were a part of creating their own care plan.