Home Health Documentation Templates for Therapists

Home Health Documentation Templates for PTs and OTs

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192 full-text examples of documentation for therapists in home health. Documentation phrases and templates to simplify and justify skilled services. Covering evaluation, outcome measures, assessments, treatments, interventions, orders, and call scripts. PDF

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What People are Saying about the Templates:

Mitchell Standford PT, DPT

"Those documentation templates are really well done! I appreciate the many hours it must have taken to compile and make user friendly. So much value packed in that pdf download!!"

Tina PT

"The OASIS goals have come in very handy and everything is organized in a way I can quickly find the examples I need."

Mark PT

"The assessment template for evaluations is perfect and adaptable to virtually every patient I see. The examples and templates cover all necessary bases without being overly wordy."

Eunice Sison PT, DPT

"Easy to use, to navigate, and shorten my documentation time in half."

Becky PT

"These templates are fantastic! I learned so many new ways to phrase interventions, goals, and assessments."

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Examples from the Templates

Homebound Status - Leaving home requires a considerable and taxing effort for the patient.
- Gait/Fatigue - Patient demonstrates reduced aerobic capacity, balance, and deterioration of gait pattern as the patient fatigues at a distance of 110ft which is insufficient to leave the home without rests breaks or direct assist of another person.
Home Safety Assessment
- Patient lives in a single story home with threshold step to enter. The home has several throw rugs and electrical cords in patient's typical walking path throughout the home. Patient's spouse agreed to secure the rugs with double sided tape and remove the electrical cords today. Patient is able to leave the home with assistance of an available caregiver or family member in case of an emergency. The home has lack of heating which presents as a significant hazard towards patient safety. Plan to address concerns: Patient's spouse scheduled maintenance to be completed this week. No other safety concerns identified at this time.
Ambulation Goal
- Patient will ambulate at least 350 ft on mixed indoor/outdoor surfaces with single point cane and with supervision to demonstrate ability to safely ambulate household distances and enter the community to attend religious services. 6 weeks.
Patient Goal
- Patient will tolerate sitting upright in wheelchair for 1 hour to enable her to participate in community BINGO activity. 4 weeks.
Dynamic gait training:
- Patient completed dynamic gait training progression including the following: fast/slow, fast, large steps, retro walking, toe walking, heel walking, tandem walking, lateral stepping, L/R turning, and dual task training (cognitive/manual) to improve safety/stability during amb/ADL performance and gait velocity. Patient required up to contact guard during today’s training and had two instances of loss of balance requiring assist of PT to prevent fall.
Response to therex:
- Patient benefited from therapeutic exercises today and it is anticipated that patient will require additional training to improve safety and indep. No complaints of ongoing pain or discomfort as a result of this training. Patient performed therapeutic exercise with no complaints of increased pain and reported Borg RPE of 5/10 which resolved to baseline within 2 mins
Balance - Perturbation
- Patient performed perturbation balance training with moderate perturbations to improve reactive balance response to improve safety with transfers, amb, and ADL/IADL performance. Patient required minimal assistance from PT to prevent loss of balance or fall. Patient was moderately unstable and required skillful balance for at least 75% of training. During balance routine patient completed motor dual tasking which included: opening and closing water bottle lid.

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192 Full Text Examples

47 Pages, color coded
Homebound Status
Social Supports
Home Safety
Subjective
Assessments

Eval, re-eval, start of care, visit, discharge

Outcome Measures

12 - Each with 4 examples

Goals and Interventions

Ambulation, assistive device training and progression, bed mobility, discharge planning, floor transfers, HEP, leave home, ROM, standing tolerance, stairs, transfers, OASIS specific goals with interventions

Treatments and Interventions

Bed mobility, transfers, gait training, therex, range of motion, AMRAP, EMOM, balance, and education

Orders

Evaluation, start of care, early discharge, frequency clarification, hold

Communication Notes

Fall, walker necessity

Call Scripts

Verbal order, fall notification, patient scheduling

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The templates are INCLUDED with the Six-Figure Home Health Jumpstart Blueprint course.

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Documentation Templates V2.1.pdf

2.23 MB