What is the standard physical therapy initial evaluation format?

Answer:
Even though most people have gotten away from hand written forms, most pre-printed forms still follow the SOAP format and may include any of the following information. (and then some...)S: (subjective). Chief compliant, pain (words to describe, intensity, location, duration, aggrevating/alleviating factors), self reported functional limiations, past medical history, results of diagnostic testing completed prior to visit, social history, prior level of function, patient goals, etc.
O: (objective)...the results of your exam: AROM/PROM, MMT, gait deviations, posture, balance, tone, muscle length, balance, transfers, standardized testing, etc.
A: (assessment). PT diagnosis, problem list, disabilities, short term goals, long term goals with prognosis
P: (plan): planned theraputic interventions, frequency and duration.

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