OAR 848-040-0130
Standards For The Documentation Of An Initial Evaluation

Except as provided in subsection (5) of OAR 848-040-0125 (Standards For Initiation Of Physical Therapy), the record of the initial evaluation shall include:

(1)

Patient’s full name, age and sex;

(2)

Identification number, if appropriate;

(3)

Referral source, including patient self-referral;

(4)

Pertinent medical or physical therapy diagnoses, medications if not otherwise accessible in another part of the patient’s medical record, history of presenting problem and current complaints and symptoms, including onset date;

(5)

Prior or concurrent services related to the provision of physical therapy services;

(6)

Any co-existing condition that affects either the goals or the plan of care;

(7)

Precautions, special problems and contraindications;

(8)

Subjective information (patient’s knowledge of problem);

(9)

Patient’s goals (with family input or family goals, if appropriate). Goals may be as
provided in an applicable IEP, IFSP, or other designated plan of care; and

(10)

Appropriate objective testing results, including but not limited to:

(a)

Critical behavior/cognitive status;

(b)

Physical status (e.g., pain, neurological, musculoskeletal, cardiovascular, pulmonary);

(c)

Functional status (for Activities of Daily Living, work, school, home or sport performance); and

(d)

Interpretation of evaluation results.

Source: Rule 848-040-0130 — Standards For The Documentation Of An Initial Evaluation, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=848-040-0130.

Last Updated

Jun. 8, 2021

Rule 848-040-0130’s source at or​.us