Treatment Plan & Goals

This plan of care translates the evaluation findings into measurable goals, prescribed interventions, and a session schedule. We will revisit and adjust it together as you progress.

Plan Header

Patient name:

Plan date:

Total expected sessions:

Plan period (e.g. "8 weeks"):

Primary impairment:

Short-Term Goals (2-4 weeks)

Long-Term Goals (8-12 weeks)

Modalities Prescribed

Select all that apply.

[ ] Heat (moist heat / hot pack)

[ ] Cold (cryotherapy / ice pack)

[ ] Therapeutic ultrasound

[ ] TENS

[ ] NMES

[ ] Interferential current (IFC)

[ ] Low-level laser therapy

[ ] Shockwave therapy

[ ] Mechanical traction

[ ] Paraffin bath

Rationale for selected modalities:

Manual Therapy

[ ] Joint mobilization

[ ] Manipulation

[ ] Soft tissue mobilization

[ ] Myofascial release

[ ] Instrument-assisted soft tissue mobilization (IASTM)

[ ] Dry needling

Regions targeted and grade / approach:

Therapeutic Exercise

Strengthening, stretching, proprioception, cardiovascular conditioning, and motor control — describe the program with progression principles.

Functional Training

Task-specific drills, return-to-work / sport progressions, ergonomic simulations:

Patient Education

[ ] Pain neuroscience education

[ ] Posture

[ ] Ergonomics

[ ] Activity pacing

[ ] Self-management strategies

Topics, resources, and discussion points:

Home Exercise Prescription (Initial Set)

Initial home program — exercises, sets / reps, frequency, duration:

Session Schedule

Frequency:

[ ] 1× per week

[ ] 2× per week

[ ] 3× per week

Session length:

Precautions & Contraindications

Postoperative weight-bearing status, healing timelines, red flags, modality contraindications:

Outcome Measures Plan

Initial scores summary:

Re-test schedule (e.g. every 4 weeks):

Discharge Criteria

Objective criteria that signal readiness for discharge from this episode of care:

Risks & Consent

I understand the risks and benefits of manual therapy, dry needling, and prescribed exercise

I consent to the treatment plan as discussed

I agree to adhere to the home exercise program to the best of my ability

Signatures

Patient signature (printed name):

Physical therapist signature (printed name):

Signing date:

I have reviewed and agree to this treatment plan

Your treatment plan is now established. We will track progress against these goals at each re-assessment and adjust the plan to keep you moving forward.