Physical Therapy Clinic
Initial evaluation, treatment plan and goals, daily treatment notes, progress re-assessment, and discharge summary with home program for outpatient physical therapy and rehabilitation clinics
Get started with PocperInitial evaluation, treatment plan and goals, daily treatment notes, progress re-assessment, and discharge summary with home program for outpatient physical therapy and rehabilitation clinics
Get started with PocperA complete record of your physical therapy episode of care, the gains made, the home program to maintain them, and what to do if symptoms return.
Patient name:
Discharge date:
Total sessions delivered:
Treatment period (e.g. "10 weeks"):
Primary diagnosis:
Initial presentation, treatment delivered, and overall response across the episode:
Goal 1 status:
Brief notes (Goal 1):
Goal 2 status:
Brief notes (Goal 2):
Goal 3 status:
Brief notes (Goal 3):
Measure 1: Baseline: Discharge:
MCID met for measure 1:
Measure 2: Baseline: Discharge:
MCID met for measure 2:
Final ROM summary:
Final MMT summary:
Residual deficits or asymmetries to monitor:
What you can do now / what still requires care:
Return-to-work / sport status:
For each exercise: name, sets / reps, frequency per week, and cue notes.
Exercise 1 — name: Sets/reps: Frequency:
Cue notes (Exercise 1):
Exercise 2 — name: Sets/reps: Frequency:
Cue notes (Exercise 2):
Exercise 3 — name: Sets/reps: Frequency:
Cue notes (Exercise 3):
Exercise 4 — name: Sets/reps: Frequency:
Cue notes (Exercise 4):
Exercise 5 — name: Sets/reps: Frequency:
Cue notes (Exercise 5):
Exercise 6 — name: Sets/reps: Frequency:
Cue notes (Exercise 6):
Exercise 7 — name: Sets/reps: Frequency:
Cue notes (Exercise 7):
Exercise 8 — name: Sets/reps: Frequency:
Cue notes (Exercise 8):
Exercise 9 — name: Sets/reps: Frequency:
Cue notes (Exercise 9):
Exercise 10 — name: Sets/reps: Frequency:
Cue notes (Exercise 10):
Exercise 11 — name: Sets/reps: Frequency:
Cue notes (Exercise 11):
Exercise 12 — name: Sets/reps: Frequency:
Cue notes (Exercise 12):
How to pace yourself, modify aggravating activities, and progress load over time:
Objective criteria to meet before full return — e.g. single-leg hop symmetry, lift capacity, endurance benchmarks.
Posture, ergonomics, warm-up, periodization, and lifestyle factors:
Sudden severe pain, neurological signs (numbness, weakness, bowel/bladder changes), unexplained swelling — contact us or seek urgent care.
Booster session schedule (e.g. "1 visit at 6 weeks"):
Check-in via phone or video call:
Next appointment date (if planned):
Orthopedist:
Sports medicine:
Nutritionist:
Mental health support:
Community group / fitness facility:
Satisfaction with PT care (1-5):
Would you recommend this clinic?
Yes — definitely
Probably
Not sure
No
Testimonial (optional — what stood out about your care?):
I give permission for the clinic to use my testimonial and photo for promotional purposes
What worked, what to apply next time, and any clinical pearls from this episode:
Patient signature (printed name):
Discharging PT signature (printed name):
Signing date:
Discharge plan reviewed and accepted
Congratulations on completing your physical therapy. Keep the home program steady, listen to your body, and reach out if anything changes — we are here when you need us.
The Discharge Summary & Home Program template is a ready-to-use form from Pocper's Physical Therapy Clinic pack. Customize the fields to match your workflow, then share a link so clients can complete it and upload documents in real time.