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: