1. Add the template
Paste this content into My Templates, or start from a specialty-generated template and edit the sections.
Physical therapy evaluation template
Use this PT evaluation template in Wavo for initial encounters where history, objective measures, clinical assessment, goals, and plan of care need a therapist-ready format.
Template content
Copy or download, then paste into Wavo under My Templates.
Physical Therapy Initial Evaluation Referral / Reason for PT - Referring diagnosis, onset/surgery date, and patient goals for therapy. History - Mechanism/onset, symptom behavior (pain scale, aggravating/easing factors), prior therapy/surgeries, and relevant medical history. - Functional limitations: walking, stairs, work, sport, sleep, ADLs. - Precautions/contraindications and weight-bearing status if applicable. Objective - Observation/posture/gait; ROM; strength; special tests; balance/transfer ability; outcome measures (e.g., LEFS, Oswestry, TUG) as performed. - Palpation and neurologic screen if indicated. Assessment - Clinical impression, impairments contributing to functional limits, and rehab potential. - Complexity and barriers to progress (pain, fear-avoidance, psychosocial factors) if relevant. Goals - Short-term and long-term functional goals with timeframes and measurable criteria. Plan of Care - Skilled interventions planned (manual therapy, therapeutic exercise, neuromuscular re-ed, gait training, modalities, education). - Frequency/duration, HEP, and anticipated discharge criteria. - Communication with referring provider as needed.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Captures functional limitations and objective measures clinicians expect in an IE.
- Supports goal writing and visit-frequency planning in one place.
- Works across orthopedic, neurologic, and general outpatient PT settings.
- Easy to customize for insurance-required elements without rewriting the whole note.
- 1Outpatient PT initial evaluations
- 2Post-operative rehab starts
- 3Neurologic and general MSK PT assessments
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Reason for PT Right ACL reconstruction 10 days ago; referred for post-op rehab. Patient goal: return to soccer next season. History Pain 3/10 at rest, 5/10 with ROM. WBAT in hinged brace. Sleep interrupted by stiffness. Ambulates with crutches for community distances. No calf pain/swelling concerning for DVT. Objective Incisions clean/dry. Knee ROM 5–85°. Quad lag 15°. Girth +2 cm vs contralateral. Ambulation antalgic with two crutches. LEFS 28/80. Assessment Post-op week ~1.5 ACLR with limited ROM, quad inhibition, and gait deviation. Good rehab potential; motivated athlete. Goals STG (2 weeks): ROM 0–110°, independent HEP, gait with one crutch community distances. LTG (12–16 weeks): ROM WNL, quad strength ≥80% contralateral on clinical testing, jog progression per protocol, LEFS ≥60. Plan of Care PT 2×/week × 8 weeks then reassess. Focus on effusion control, extension/flexion ROM, quad activation, gait normalization, and education on ACL protocol phases. HEP issued. Update surgeon at 6-week milestone.
How Wavo automates this
What the product actually does with your template.
2. Record or dictate
Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.
3. Review and sign
Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.
Put this template to work on your next visit
Start free, paste the template, and see how Wavo documents in your structure.