Physical Therapist (PT) Performance Evaluation

Date of Hire :

Date of Evaluation :

Probationary Evaluation

Annual Evaluation

Responsibility, Skill, or Procedure

Yes

No

Completes the following intake documents thoroughly and accurately :

Intake Form

Yes

Consent for Treatment

Yes

Statement of Financial Disclosure

Yes

Admission Checklist

Yes

Insurance Card Verification/Medicare Secondary Payer

Yes

Reviews and discusses with patient/family the following information :

Patient’s Bill of Rights

Yes

Statement of Non-Discrimination

Yes

Advance Directive/Living Will

Yes

HIPAA/Privacy Practices Notice

Yes

OASIS Consent

Yes

How to contact the agency/lodge a complaint/Home Health Hotline

Yes

In-Home Safety Checklist

Yes

Completes the following thoroughly and accurately :

Therapeutic/rehab/functional status assessments of patients

Yes

Assessments for muscle strength, mobility, gait, ROM & transfer

Yes

Instructs patients, families and caregivers in exercise regimen and the use and care of therapeutic appliances :

Determines priority needs for physical therapy

Yes

Provides training in ambulation, transferring, gait and home exercise

Yes

Assesses patient home environment and identifies equipment needs

Yes

Evaluates ability to perform ADLs in home/social environment

Yes

Completes the following medical records thoroughly, timely and accurately :

Physical Therapy Assessment

Yes

OASIS Documentation

Yes

Progress Notes (as needed)

Yes

Discharge/Transfer Record

Yes

Clearly communicates with physician regarding :

Plan of Care development and changes to plan of care (HCFA 485)

Yes

Observations & Clinical Changes

Yes

Obtaining verbal orders

Yes

Identifies and assists patient/family in accessing community resources including :

Durable Medical Equipment/supplies

Yes

Access to other resources through referral to other team members or community programs relative to patient’s needs

Yes

Home Health Aide :

Develops Home Health Aide Plan of Care as Required

Yes

Instructs Home Health Aide in Plan of Care as Required

Yes

Performs Home Health Aide Supervisory Visits every 14 days

Yes

Communicates appropriately with the other members of healthcare team including :

Nurse

Yes

Occupational Therapist

Yes

Speech-Language Pathologist

Yes

Medical Social Worker

Yes

Home Health Aide

Yes

Other: (identify) :

Yes

Supervision of PTA :

Performs PTA Supervisory Visits every 30 days

Yes

Other areas/skills :

Performs teaching to client/family/home health aide

Yes

Maintains client confidentiality/HIPAA

Yes

Conducts self in a professional manner

Yes

Reports to Supervisor as needed and appropriate

Yes

Maintains Infection Control Guidelines for hand washing, etc

Yes

Participates in interdisciplinary/case/team conferences as needed

Yes

Date :

My signature below does not imply my agreement with the content of this evaluation, but that the above evaluation has been reviewed with me.