Department of Medical Assistance Services / Local Education Agency Services

Physical Therapy Progress Notes

 

Student Name:

     

 

     

MM/YY:

     

 

Last

 

First

 

Medicaid/FAMIS #:

                                   

                                 DOB:       ______________

 

 

 

     

 

     

Therapist/Asst. Therapist  Signature & Title

Therapist/Asst. Therapist Printed Name

 

Initials

 

 

     

Supervising Therapist Signature & Title  (as applicable)

Supervising Therapist Printed Name

 

Treatment Log

Date

(mm/dd)

*Type of  Contact

Physical Therapy Activity

Student response to treatment

(must be measurable)

Initials

of Provider

 

     

Select one

 

 Gait Training                   Locomotor Skills

 Balance                            Coordination      

 Transfer Training            Motor planning

 Strength/Endurance         Spatial Awareness

 Ex. Program/ROM          Ball Skills

 Staff/Caregiver Instruc    Equip Mngmnt

      

     

 

 

     

Select one

 

 

 Gait Training                   Locomotor Skills

 Balance                            Coordination      

 Transfer Training            Motor planning

 Strength/Endurance         Spatial Awareness

 Ex. Program/ROM          Ball Skills

 Staff/Caregiver Instruc    Equip Mngmnt

      

     

 

 

     

Select one

 

 

 Gait Training                   Locomotor Skills

 Balance                            Coordination      

 Transfer Training            Motor planning

 Strength/Endurance         Spatial Awareness

 Ex. Program/ROM          Ball Skills

 Staff/Caregiver Instruc    Equip Mngmnt

      

     

 

 

     

Select one

 

 

 Gait Training                   Locomotor Skills

 Balance                            Coordination      

 Transfer Training            Motor planning

 Strength/Endurance         Spatial Awareness

 Ex. Program/ROM          Ball Skills

 Staff/Caregiver Instruc    Equip Mngmnt

      

     

 

 

 

Student Name:

     

 

     

MM/YY

     

 

Last

First

Medicaid/FAMIS #:

     

 

 

 

Date

(mm/dd)

*Type of  Contact

Physical Therapy Activity

Student response to treatment

(must be measurable)

Initials

of Provider

 

 

     

Select one

 

 

 Gait Training                   Locomotor Skills

 Balance                            Coordination      

 Transfer Training            Motor planning

 Strength/Endurance         Spatial Awareness

 Ex. Program/ROM          Ball Skills

 Staff/Caregiver Instruc    Equip Mngmnt

      

     

 

 

 

     

Select one

 

 

 Gait Training                   Locomotor Skills

 Balance                            Coordination      

 Transfer Training            Motor planning

 Strength/Endurance         Spatial Awareness

 Ex. Program/ROM          Ball Skills

 Staff/Caregiver Instruc    Equip Mngmnt

      

     

 

 

 

     

Select one

 

 Gait Training                   Locomotor Skills

 Balance                            Coordination      

 Transfer Training            Motor planning

 Strength/Endurance         Spatial Awareness

 Ex. Program/ROM          Ball Skills

 Staff/Caregiver Instruc    Equip Mngmnt

      

     

 

 

 

Select one

 

 Gait Training                   Locomotor Skills

 Balance                            Coordination      

 Transfer Training            Motor planning

 Strength/Endurance         Spatial Awareness

 Ex. Program/ROM          Ball Skills

 Staff/Caregiver Instruc    Equip Mngmnt

      

 

 

 

 

Select one

 

 Gait Training                   Locomotor Skills

 Balance                            Coordination      

 Transfer Training            Motor planning

 Strength/Endurance         Spatial Awareness

 Ex. Program/ROM          Ball Skills

 Staff/Caregiver Instruc    Equip Mngmnt

      

 

 

 

 

     

Select one

 

 

 Gait Training                   Locomotor Skills

 Balance                            Coordination      

 Transfer Training            Motor planning

 Strength/Endurance         Spatial Awareness

 Ex. Program/ROM          Ball Skills

 Staff/Caregiver Instruc    Equip Mngmnt

      

     

 

 

Student Name:

     

 

     

MM/YY

     

 

Last

First

Medicaid/FAMIS #:

     

 

 

Date

(mm/dd)

*Type of  Contact

Physical Therapy Activity

Student response to treatment

(must be measurable)

Initials

of Provider

 

     

Select one

 

 

 Gait Training                   Locomotor Skills

 Balance                            Coordination      

 Transfer Training            Motor planning

 Strength/Endurance         Spatial Awareness

 Ex. Program/ROM          Ball Skills

 Staff/Caregiver Instruc    Equip Mngmnt

      

     

 

 

     

Select one

 

 

 Gait Training                   Locomotor Skills

 Balance                            Coordination      

 Transfer Training            Motor planning

 Strength/Endurance         Spatial Awareness

 Ex. Program/ROM          Ball Skills

 Staff/Caregiver Instruc    Equip Mngmnt

      

     

 

 

 

 Gait Training                   Locomotor Skills

 Balance                            Coordination      

 Transfer Training            Motor planning

 Strength/Endurance         Spatial Awareness

 Ex. Program/ROM          Ball Skills

 Staff/Caregiver Instruc    Equip Mngmnt

      

 

 

 

     

Select one

 

 

 Gait Training                   Locomotor Skills

 Balance                            Coordination      

 Transfer Training            Motor planning

 Strength/Endurance         Spatial Awareness

 Ex. Program/ROM          Ball Skills

 Staff/Caregiver Instruc    Equip Mngmnt

      

     

 

 

Supervision Visit                    

Completion Date:

     

 

 Reviewed Progress

 Reviewed Goals

 Continue with Plan Of Care

Status:

  Progressing

 Not Progressing

  Maintaining      

Comments/Recommendations: 

     

Supervising Therapist Signature /Title and Date:                              

 

Therapy Assistant Signature /Title and Date: