Neurological Physical Therapy Documentation
Patient Name
Medical Record Number
Date
Therapist
Diagnosis
Referral/Physician
Chief Complaint
History of Present Illness
Subjective
Patient Report
Objective
Observation/Posture
Mental Status/Cognition
Sensation
Muscle Tone
Range of Motion
Strength
Coordination
Balance
Functional Mobility (Transfers, Gait, etc.)
Assessment
Summary/Analysis
Problems Identified
Plan
Treatment Plan
Goals