How To Write a Physical Therapy Evaluation 

A physical therapy evaluation is the synthesis of all the information you gather during a physical therapy examination. Let's review a physical therapy examination and how to write up your findings in a physical therapy evaluation.
You can find all the templates here:
Evaluation Template: www.ptprogress.com/eval
Assessment/Goal Template Bundle: www.ptprogress.com/templates
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Timestamps:
0:00 - Intro
1:00 - What is a Therapy Evaluation?
3:28 - Clinical Examination
8:54 - Written Evaluation
14:53 - Full Evaluation Example
Clinical Examination: Most clinics will set aside 45 to 60 minutes for the initial evaluation. During the evaluation, you’ll cover a lot of information, which may include:
Patient’s Medical History
Systems Review
Tests & Measures
Posture & Gait Analysis
Range of Motion & Muscle Strength Testing
Special Tests
Home Exercise Prescription
Goal Setting
Treatment Recommendations
For an in depth look at how to structure your PT eval, check out the Therapy Evaluation Templates
Key Components of a Physical Therapy Evaluation
While the overall structure of a physical therapy evaluation does follow a broad SOAP note format, you’ll cover a lot more detail in this initial note than in most follow up notes or daily notes.
Subjective / Chief Complaint / Past Medical History
Objective Testing / Special Tests / Relevant Data
Assessment, Diagnosis, Prognosis, & Goals
Plan of Care
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