Essential Components of a Physical Therapy Initial Prescription
A comprehensive physical therapy prescription must include patient information, specific therapy details, assessment findings, exercise parameters, and communication elements to ensure optimal patient outcomes.
Core Patient and Administrative Information
- Patient's full name, date of birth, contact information, and relevant medical record numbers 1
- Diagnosis or condition requiring physical therapy 2
- Date of prescription and physician signature 2
- Insurance information and authorization details when applicable 1
Assessment Information
- Relevant medical history and comorbidities that may affect therapy 1
- Functional assessment results (baseline measurements of pain, range of motion, strength, balance, walking ability) 1
- Previous physical activity level and current capabilities/limitations 1
- Disease-specific assessment findings (e.g., cardiovascular status, weight-bearing restrictions) 1
Specific Therapy Details
- Type of therapy needed (e.g., aerobic exercise, resistance training, flexibility exercises, aquatic therapy) 1, 3
- Specific interventions or modalities to be used (e.g., manual therapy, therapeutic ultrasound) 2
- Precautions and contraindications based on patient condition 3
- Safety parameters (e.g., vital signs monitoring requirements, exercise termination criteria) 1
Exercise Prescription Parameters (FITT-PRO)
- Frequency: Number of sessions per week 1, 3
- Intensity: Appropriate resistance levels (e.g., 40-60% of 1-RM for resistance training) 3
- Time: Duration of each session and individual exercises 1
- Type: Specific exercises targeting affected areas 1
- Progression: Guidelines for advancing the program as patient improves 1
- Rest: Appropriate rest periods between exercises 3
Goals and Outcomes
- Specific, measurable functional goals to be achieved 1, 4
- Timeline for expected progress and achievement of goals 1
- Criteria for discharge or program modification 1
Communication Elements
- Instructions for interdisciplinary coordination between PT and other healthcare team members 1
- Follow-up plan including timeline for reassessment 1
- Guidelines for home exercise program 1
- Requirements for progress reporting back to the referring physician 2
Disease-Specific Considerations
- For cardiovascular patients: Include exercise test results, target heart rate ranges, and monitoring requirements 1, 3
- For musculoskeletal conditions: Specify weight-bearing restrictions and movement limitations 1
- For neurological conditions: Include assessment of sensorimotor function and cognitive abilities 1
- For pulmonary conditions: Note respiratory function parameters and oxygen requirements 1
Common Pitfalls to Avoid
- Avoid vague prescriptions like "evaluate and treat" without specific parameters 1
- Include progression planning to prevent stagnation in the program 1
- Don't neglect functional goals in favor of focusing solely on impairments 1
- Ensure safety parameters are clearly defined for high-risk patients 1, 3
Example Template Format
- Patient Information: [Name, DOB, Contact Info, Medical Record #]
- Diagnosis: [Specific condition]
- Precautions/Contraindications: [Any limitations]
- Treatment Frequency: [# sessions per week] for [# weeks]
- Treatment Goals: [Specific functional outcomes]
- Exercise Parameters: [FITT-PRO details]
- Special Instructions: [Any specific requirements]
- Follow-up Plan: [Reassessment timeline]
- Physician Signature and Date 2