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Following completion of this chapter, the reader will be able to:

  • Describe value-based physical therapy.

  • Discuss why strength and range of motion are best described in numbers as fractions, but tone, which can also be described in fractions, is preferably described in verbiage.

  • Explain rehabilitation potential in the context of physical therapy.

  • Identify two components included in muscle performance and provide an example for each.

  • Explain the relationship between safety/risk reduction and strength.

  • Explain why precautions and contraindications are necessary relative to physical therapy intervention and their relationship to medical necessity.

  • Describe the different levels of evaluation.

  • Discuss examples of objective descriptions of:

    1. Gait

    2. Range of motion

    3. Balance

    4. Strength

    5. Wheelchair mobility

    6. Motor control

In previous chapters we discussed what should be included when documenting the initial evaluation, daily notes, progress reports, and discharge summary. It is important for the documentation to reflect the need for skilled service. In this chapter we discuss in detail the documentation considerations for the different aspects of the physical therapy evaluation document (including goal writing). This document requires the following components: History, Examination, Clinical Presentation, and Clinical Decision-Making. These components will be used to demonstrate how the clinician selects the appropriate level of evaluation and the value of physical therapy. It is important to demonstrate the value of physical therapy.


Physical therapists (PTs) have been using a systematic approach to evaluate the patient and to determine the patient dysfunctions that need to be addressed. When documenting on this and subsequent patient encounters, please consider the definitions that the Centers for Medicare & Medicaid Services (CMS)1 uses and the fact that not all forms of assessment are reimbursable.


The process that the PT uses “that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted e.g., for a new diagnosis or when a condition is treated in a new setting. These evaluative judgments are essential to development of the plan of care, including goals and the selection of interventions.”1


Assessment is separate from the evaluation and is included in services or procedures, (it is not separately payable). “Assessments shall be provided only by clinicians, because assessment requires professional skill to gather data by observation and patient inquiry and may include limited objective testing and measurement to make clinical judgments regarding the patient’s condition(s). Assessment determines, e.g., changes in the patient’s status since the last visit/treatment day and whether the planned procedure or service should be modified. Based on these assessment data, the professional may make judgments about progress toward goals and/or determine that a more complete evaluation or re-evaluation (see definitions later) is indicated. Routine ...

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