Also called a 30-Day Reassessment
This is much the same as a normal routine visit except you need to summarize what has happened during the last 30 days. Pretty easy to do.
It will appear as a PT10. Be sure to Remember to click the drop down and check 30 Day Reassessment Visit as you enter the visit. This resets the clock.
- The Therapy Assess/Plan section is where you summarize the progress or the decline.
- I start with a statement like this: This is a 30-day reassessment visit and the patient has improved/declined in the following areas:
- Then, I pick 2-3 objective measurements that I can show progress or decline on. Find them at:
- Therapy Goals/Status section. Look at one like Balance, which is the TUG test score. Do a long-hold on TUG and click on history. See what the score was 30 days ago and remember that.
- Go back to Therapy Assess/Plan and add: TUG has improved from ____ seconds to ____ seconds using FWW. If it declined add a line that may suggest a reason why they did not do as well: pain, poor sleep, dizziness, etcA finished Assessment and Plan might look something like this:
Assessment: This is a 30-day reassessment visit and the patient has improved/declined in the following areas: TUG improved from 60 seconds to 30 seconds with FWW. The 30-second sit to stand declined from 6 repetitions to 3 repetitions possibly due to arthritic exacerbation in left hip. Gait, with single effort, improved from 75 feet to 100 feet. Patient requires verbal cues for proper sit to stand hand and foot placement and requires min assist while moving from sitting to standing indicating that his hip and knee extensor muscles require more strengthening. Verbal cues are also required during gait training to encourage him to advance his foot forward and outward to avoid cross adduction or scissor gait. I checked the length of his hip adductors and did not observe hypertension or restriction in hip abduction range of motion.
Plan: (for next visit) Strengthen hip and knee extensors with BLE PNF and or progressive sit to stands. Review proper hand and foot placement for moving from sitting to standing. Give verbal cues for proper swing through foot placement to avoid cross adduction. (Hint: Write this Plan as though you are writing to an assistant to let them know exactly what you want to accomplish on the next visit.
These two sections are the A and the P of your SOAP Note.