Whether you are fresh out of PT school or you are a 20-year seasoned veteran of the outpatient PT world, understanding and completing a physical therapy evaluation lays the groundwork for defensible documentation that is so necessary for reimbursement today. But completing a good initial evaluation is an art form. And like any craft, practicing and honing your skills is a must.
To help, EMRs have long since held center stage for documentation simplicity and efficiency while ensuring behind-the-scenes regulatory checks are completed. And while less time spent on a computer to document is great, every therapist must keep in mind that their craft starts with the evaluation by way of human interaction. So, let’s jump into this explainer of how to create a rock-solid eval—complete with a physical therapy evaluation example of our own.
The Difference Between an Evaluation and Examination
Oftentimes, the words evaluation and examination are used synonymously to the confusion of clinicians and patients alike. But don’t fall prey to this pitfall. A complete PT evaluation starts with a clinical examination comprising the patient history, systems review, and objective data collection. Then, the PT communicates their findings in an evaluation followed by a prescribed plan of care (POC). Just remember that an evaluation cannot be completed without a thorough examination of the patient.
Ultimately, think of a full evaluation as a very in-depth SOAP note—the subjective, objective, assessment, and plan analyses for a patient’s treatment. Let’s break this down.
Before jumping onto your stool and interviewing your patient, take a moment to review information like their prescriptions, demographics, pain chart, past medical history, and current medications. These can be collected ahead of time—and transferred directly to the patient chart—with useful tools like digital patient intake forms.
You should also consider administering a patient-related outcome measure (PROM) at this stage, as well. Technically, this can be completed before, during, or after the evaluation—you’ll decide what works best for your workflows. However, if you find yourself pressed for time, or appreciate the ability to review scores ahead of time, tracking PROMs through an application built to manage this data can give valuable insight to your patient’s needs, and ultimately boost outcomes.
The Subjective Examination
Often overlooked, but likely the most important part of the evaluation is the subjective examination. It initiates the clinical reasoning from which you will develop your diagnosis and POC. It is so important, in fact, that Nobel Peace Prize laureate Bernard Louw has stated, “medical history provides sufficient information in about 75% of patient encounters to make the diagnosis before performing a physical examination and additional tests.”
Knowing where, when, and how to start interviewing your patient requires practice. Starting with guided questions that are open-ended with a funnel-down approach provides therapists with a template to accurately and efficiently collect this information. A few of the topics that should be covered during the subjective examination include, but are not limited to:
- Chief patient complaints;
- Previous level of function;
- Mechanism of injury (MOI);
- Employment and work history;
- Medical and surgical history; and
- SINSS (which stands for severity, irritability, nature, stage, and stability regarding the patient’s condition).
Gathering intel via the SINSS model will create a clear picture of why the patient has come to you and where you can start working toward their road to recovery.
Objective Measures in a Patient Examination
With all the subjective examination data collected, you can now use all those skills you learned from PT school to gather the relevant information pertaining to your patient’s primary complaint, as well as any related deficits that will need to be addressed going forward. These factors include:
- Neighboring joints and systems screening;
- Active and passive range of motion collection;
- Muscle length testing;
- Manual muscle testing;
- Neurodynamic testing;
- Palpation and joint accessory motion testing;
- Additional outcome measures;
- Special tests;
- Gait analysis; and
- Anything else that is objectifiable.
As you can see, the special tests are completed toward the end of the objective data collection. This is done intentionally to remind PTs that special tests are used to confirm or rule out a diagnosis based on the other data that was collected. Reliance on special tests for clinical decision-making is a pitfall many therapists have fallen prey to in the past, so trust in your clinical reasoning skills before leaning too heavily on a gamut of eponymously named special tests.
Now that all this subjective and objective data has been collected, it must be compiled into a succinct assessment of the patient’s need for physical therapy, while also clearly stating the treatment diagnosis, prognosis, and goals.
In some instances, the diagnosis is already written on the prescription, but as many therapists know, the medical diagnosis on the prescription may not align with the treatment diagnosis. Or, perhaps the patient came to physical therapy via direct access with no prescription at all. To stay on task, focus on the treatment diagnosis representing the injury or condition that you—the therapist—are treating. This treatment diagnosis will be identified by an ICD-10 code.
With every assessment of the patient, there must also include a statement of the patient’s prognosis. Simply stating excellent, good, fair, or poor is no longer sufficient. Providing examples as to why you have assigned this prognosis is required. Some of these factors include:
- Comorbidities and past medical history;
- Acuity of the injury or primary complaint; or
- Nature of the dysfunction or related disease processes.
Providing a list of goals for the patient to achieve as a result of skilled PT services is a required next step. For this, I recommend using SMART goals. Follow this model to ensure your patients’ goals are:
- Specific about the who, what, where, when, and why;
- Measurable so that you can properly monitor progress;
- Attainable in a reasonable and necessary timeframe;
- Realistic in regards to achieving a specific function and purpose; and
- Time-bound in that they give limits and clear dates to measure progress.
Goal setting is not a one-way street. This requires a conversation with your patient to determine which goals fit best into their personal therapy journey.
Plan of Care
For Medicare beneficiaries receiving physical therapy, a POC is a regulatory must. For other insurers (or cash-pay practitioners) the rules differ. Regardless, the POC provides the evaluating PT a chance to describe how physical therapy is going to solve a particular patient’s functional problems. The assessment has fulfilled much of the POC’s requirements. What remains is to state the frequency and duration for which the patient will need services and the planned interventions you think will benefit this patient most in achieving their goals.
The evaluation is nearly complete, but there is one final step: designating the complexity of the evaluation. Federal and commercial payers started requiring more specific CPT codes for evaluations in 2017 to better quantify and reflect the complexity of patients’ injuries, and thus their prescribed treatment. There are three CPT codes that define complexities as low (97161), moderate (97162), or high (97163). To assist you in choosing the right code for a given case, five categories are used to qualify each level of complexity:
- Clinical presentation; and
- Decision making.
For more insight on this topic, check out our one-page guide on how to select the right complexity for your evaluations.
Physical Therapy Evaluation Example
So we have covered the basics of a good physical therapy evaluation, but for any visual learners out there, here is an example of one. For simplicity’s sake, we kept it in a standard SOAP format.
Michael comes to therapy reporting a sudden onset of calf pain following the recent “Dunder Mifflin Scranton Meredith Palmer Memorial Celebrity Rabies Awareness Pro-Am Fun Run Race for the Cure.” He states that after starting out too fast, he felt a sudden pulling and cramping sensation deep within the calf muscle and had to walk the rest of the race. Using a SINSS model, the evaluating therapist concludes the following:
- Severity: using the visual analog scale (VAS), pain is rated a 3/10 presently, 6/10 at worst, and 1/10 at best.
- Irritability: pain is worse with climbing stairs, stretching the calf, sitting to a low surface, and running. Pain is alleviated with rest, ice, and massage.
- Nature: there do not appear to be any red or yellow flags, pain appears mechanical in nature.
- Stage: the injury occurred two weeks ago, and is in the late acute stage of healing.
- Stability: the patient states they are improving.
Michael’s past medical history is significant for a right foot burn two years ago (on a George Foreman grill), anxiety, and hypertension. He has completed an outcome measure via his digital intake forms and scored a 68/80 on the Lower Extremity Functional Scale (LEFS).
Objective Tests and Measures
The following deficits were found in Michael’s examination:
- Hip and knee involvement has been screened as uninvolved.
- Range of motion measurements (ROM):
- Limited and painful active and passive ankle dorsiflexion ROM.
- Muscle length testing:
- Gastrocnemius length testing positive for tightness.
- Manual muscle testing:
- Gastrocnemius and soleus manual muscle testing reveals pain and weakness of the gastrocnemius more so than the soleus.
- Neurodynamic testing:
- Straight leg testing to bias the sural, tibial, sciatic, and common peroneal nerves is negative.
- Palpation and joint accessory motion testing:
- Positive tenderness to palpation in the medial gastrocnemius muscle belly with absence of any warmth or redness. Normal accessory mobility in the ankle/foot.
- Special tests:
- Homan’s sign is negative for the presence of deep vein thrombosis (DVT).
- Gait analysis reveals an antalgic gait pattern with decreased heel strike at initial contact and early heel rise at terminal stance.
- Functional assessment of gastrocnemius strength: patient can complete five unilateral heel raises on the involved side compared with 25 on the uninvolved side.
Michael presents with pain and stiffness following an acute strain to the medial gastrocnemius muscle suffered two weeks ago with deficits in range of motion and strength in the lower limb as well as an abnormal gait pattern, and intolerance to functional activities of running, stairs, and sitting to low surfaces. He would benefit from skilled physical therapy services to address these impairments and restore normal ROM and strength in the lower limb while reducing pain and improving activity participation. Due to his motivation to run again and return to a pain-free prior level of function, Michael has a good prognosis.
Michael’s goals are as follows:
- Improve active and passive ROM into dorsiflexion to at least 15 degrees in order to ambulate with a normalized heel strike at initial contact in three weeks.
- In three weeks’ time, Michael will no longer complain of pain when ascending steps over the course of an eight-hour work day.
- Improve calf strength to perform 25 unilateral heel raises on the involved side for improved ability to propel himself when running and negotiating steps by six weeks.
- Improve the LEFS by at least 9 points to match the minimal clinically important difference for return to normal function by six weeks.
Plan of Care
To meet these goals, Michael would benefit most from skilled therapy to be received twice a week for six weeks. Skilled PT interventions will consist of:
- Therapeutic exercise (97110);
- Therapeutic activity (97530);
- Neuromuscular re-education (97112);
- Manual therapy (97140);
- Gait training (97116);
- Therapeutic modalities using cryotherapy and thermotherapy PRN (97010); and
- Unattended electrical stimulation for pain control PRN (G0283).
Low complexity evaluation (97161) due to a 20-minute duration, a past medical history without any personal factors and/or comorbidities that could impact the POC, examination of body systems completed on one to two elements, the patient presents with a stable condition, and clinical decision making using the LEFS was of low complexity.
Well, there you have it. The what, how, when, why, and practically every other question in between answered on how to craft a comprehensive and defensible physical therapy evaluation. Have any additional evaluation tips, tricks, or just a simple question? Drop us a line in the comment section below and our team will do their best to answer them.