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Table of Contents

• Needed Items
• Needed Forms
• Evaluation Thought Process
• Evaluation Procedures
• Key to success!
• Important reminder!
• Resource Links

 

 

 

 

 

 

Needed Items

The evaluation tools needed will depend on your niche or specialty. For example if you are specializing in knee patients it's a good idea to have a biodex or kincom, etc.  Nevertheless, there are basic evaluation tools you'll need:

1. Goniometer

2. Reflex Hammer

3. Pinwheel (sensory testing)

4. Hand dynamometer

5. Step stool

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Needed Forms

You will need an evaluation form with the following forms/documents:

1. Evaluation form

The first page should be a pre-exam form and the rest for your SOAP.

 

2. Patients Role Sheet

A sheet that you give the patient to write down your instructions on things they should not do, things they should do, and home exercise instruction. This one tool will help you increase outcomes and get patients better faster!

 

3. PT orders form

A prescription note pad you use when wanting to communicate the patients precautions/contraindications to their employer, teacher, etc.  Patients will ask you for a note frequently.

 

4. MD request form

You will frequently make requests to the primary care physician regarding patient needs items such as  home TENS unit, extension on a patients script, request for orthotics, etc.  Make it simple by having a checklist type request form.

 

5. Disabilities Recommendation form

You will periodically be asked to give a report or your professional opinion on a patient's disability status.  Have a quick form to check off and send (you should charge for this report).

 

See our CD of Tools for all your necessary forms and documents.

 

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Evaluation Thought Process

 

You can't perform your evaluations the way you did when working for someone else. Now that you have your own business it is paramount to perform fast and efficient evaluations where the patient feels they received more than they expected.  In order to accomplish this you must be clear in your approach to the evaluation thought process. They are:

 

1. Profile the patient

Not all patients will be good candidates for your care. Some may have an incentive NOT to get better. Like some worker's compensation patients, etc.  You need to get good at determining which ones won't get better or don't really need your services.  Remember that every patient has the potential to bring good or bad reputation to your business. Don't be afraid to let some patients go.

 

2. Hypothesis

If the patient is a good candidate and you perform a subjective exam, establish a hypothesis of the exact structures at fault.  Then and only then go into your objective exam to confirm what you think it may be.

 

3. Assessment

After confirmation, specify the exact structure causing the problem/pain in your assessment. Be as specific as you can.

 

4. Establish Baseline Data

Once a specific assessment has been made than collect all your baseline measures for future progress indicators.

 

5. Educate

Help motivate the patient by explaining (as much as they need to know) about their problem.

 

6. Define Roles

This is where you design the solution to their problem.  The first step toward recovery is your ability to make the patient understand what their role is during the rehabilitation program.  Their are over 160 hours in a given week and if they spend only one hour a day, three times per week at getting better that is only 3 hours out of 168 (less than 2%).  You won't get good outcomes this way.  Make sure the patient understands the following after every evaluation:

• Things they are NOT supposed to do.
• Things they SHOULD do.
• Home exercises.

See our sample "Patients Role Sheet".

 

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Evaluation Procedures

 

There are several questions that must be answered in order to have a smooth evaluation procedure.

1. How long will you allot for each evaluation (remember documentation time)?

I recommend anywhere from 45-60 minutes for an evaluation.  This leaves enough time to complete the necessary documentation.

 

2. After every evaluation, how will you communicate the recommended frequency & duration the patient's supposed to schedule their future appointments to your front office scheduler.  This may be an easy question for some of you who plan to merely walk up to the front and tell them the recommended frequency and duration (don't blindly go by the MD's referral).  I recommend using our patient's role sheet, which automates this step.  At the bottom of the sheet you check off your recommended frequency and duration, give to patient and remind them to show the scheduling person at the front.

 

3. How will your evaluation report get transmitted to the patient's referring physician?

This is a real issue.  If your system does not make it easy for you to send reports or correspondences, most likely you won't communicate consistently.  If you don't communicate consistently with the MD's it may negatively affect their impression of you and your level of care.  I recommend having a staff member designated to processing all reports and correspondences (Some use transcriptionists but I believe it to be too tedious and expensive).

• Set up a computer with hi-speed internet connection at your charting station.
• Use a web-based form to input evaluation data that sends the data to an email.
• Have your staff cut and paste the data from the email to a report template and fax off the report.

See sample of this process

 

This method is faster, less expensive, and more flexible than any other way.

 

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Key to Success

Efficient evaluations can only be realized when all the necessary tools, documents, and supplies are stocked and within convenient reach of the therapist in the examination rooms.  The inventory and stocking of the exam room is a good task for an aide.

 

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Important Reminder

Remember that the evaluation is the most skilled of all therapist tasks, and it's the best time to make a lasting impression of high value on your new patients.

 

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Resource Links

• If you have any trouble with this section then consult with James Ko at 1.800.801.4511 ext. 701 or jamesko@indefree

 

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