A physical therapy progress report re-measures the patient partway through care and decides whether to continue, change the plan, or discharge. Copy the free template, see two filled examples, and check how to set measures beside the baseline and justify the next step.
Blank physical therapy progress report template
FreePHYSICAL THERAPY PROGRESS REPORT Patient: [Name] Date of birth: [Date] Date of report: [Date] Reporting period: [First and last date covered] Visits to date: [Visits attended, canceled, and missed] Treatment diagnosis: [Condition and body region] Referring clinician: [Name, if any] Therapist: [Name, credentials] SUMMARY OF CARE Interventions provided: [Main interventions this period] Patient report: [Change in symptoms and function since the evaluation or last report] Home program adherence: [How consistently it is done] MEASURES Pain: Initial [score out of 10] | Now [score out of 10] Range of motion: Initial [joint, motion, degrees] | Now [degrees] | Other side [degrees] Strength: Initial [muscle group, grade] | Now [grade] | Other side [grade] Balance or gait: Initial [test, result] | Now [result] Outcome measure: Initial [name, score] | Now [score] | Change [points] GOAL STATUS Goal 1: [Goal] | Baseline [value] | Now [value] | Status [met, progressing, or not met] Goal 2: [Goal] | Baseline [value] | Now [value] | Status [met, progressing, or not met] Goal 3: [Goal] | Baseline [value] | Now [value] | Status [met, progressing, or not met] ASSESSMENT Progress: [What changed, and whether the change is meaningful for function] Remaining limitations: [Impairments and activity limitations still present] Barriers: [Anything slowing progress, and how you are addressing it] UPDATED GOALS New or revised goals: [Measurable, functional, with a time frame] RECOMMENDATION Decision: [Continue, change the plan, or discharge] Justification: [Why skilled care is still needed, or why it no longer is] Plan: [Frequency, duration, and changes to interventions] Report sent to: [Referring clinician or others] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Outpatient sports clinic, re-assessment
27-year-old man, 6 weeks after a right lateral ankle sprain playing soccer; X-ray showed no fracture. 10 visits over 5 weeks, none missed. Care has included ankle mobility work, strengthening, balance and hop progressions, and running drills. Walks and climbs stairs without pain. Jogged 10 minutes twice this week with a mild ache, 2/10. Does the home program 5 or 6 days a week.
Pain with activity: initial 6/10, now 1/10. Dorsiflexion, knee-to-wall: initial 4 cm (1.6 in), now 10 cm (3.9 in); left 12 cm (4.7 in). Eversion strength: initial 3+/5, now 5/5. Single-leg heel raises: initial 6, now 22; left 28. Single-leg balance, eyes closed: initial 5 s, now 25 s; left 30 s. Y Balance Test anterior reach: not tested initially; now 5 cm (2 in) short of the left. Foot and Ankle Ability Measure sports subscale: initial 34%, now 72%.
Goal 1, walk and climb stairs without pain: baseline 6/10 on stairs, now 0/10. Met. Goal 2, single-leg balance with eyes closed for 30 s: baseline 5 s, now 25 s. Progressing. Goal 3, run 20 minutes without pain: baseline unable, now 10 minutes at 2/10. Progressing. Goal 4, return to soccer: not met; hop and agility testing not yet passed.
Good progress. Pain, eversion strength, and dorsiflexion are close to the other side, and the FAAM sports score has more than doubled. Still limited: calf endurance, balance when fatigued, and cutting and hopping, which he has not yet been cleared to start. Lateral ankle sprains often recur, and he is not yet ready for match play.
By 3 weeks: run 30 minutes on mixed surfaces without pain; 25 or more single-leg heel raises; Y Balance anterior reach within 4 cm (1.6 in) of the left; hop and agility tests with the right side at 90% or more of the left, without pain or apprehension; back to full team training.
Continue once a week for 3 weeks with a sport-specific home program, then discharge after return-to-sport testing. Skilled care is needed to progress hopping, cutting, and agility safely and to judge readiness for sport. Report sent to his family physician.
Outpatient neurological rehab, re-assessment
67-year-old woman with Parkinson’s disease for 4 years, Hoehn and Yahr stage 3, referred after 2 falls in 6 months. 14 of 16 planned visits over 8 weeks; 2 missed for a medication review. Twice-weekly program: high-amplitude movement practice, gait training with visual and auditory cues, dual-task walking, reactive balance training, and fall prevention education. Sessions booked about an hour after her carbidopa-levodopa dose. One fall in 8 weeks, a trip on uneven ground outdoors, with no injury. Freezes in doorways less often. Walks 20 minutes, 4 days a week.
Mini-BESTest: initial 16/28, now 20/28. Functional Gait Assessment: initial 15/30, now 19/30. Timed Up and Go: initial 14.2 s, now 11.8 s; with a counting task, initial 19.5 s, now 15.1 s. Gait speed: initial 0.86 m/s, now 1.02 m/s. Five Times Sit to Stand: initial 17.4 s, now 13.9 s. Activities-specific Balance Confidence Scale: initial 58%, now 70%.
Goal 1, Mini-BESTest 20/28 or higher: baseline 16, now 20. Met. Goal 2, Timed Up and Go under 12 s: baseline 14.2 s, now 11.8 s. Met. Goal 3, walk through doorways at home without freezing: baseline daily freezing, now once or twice a week. Progressing. Goal 4, no falls over 8 weeks: 1 fall. Not met.
Good response to balance and gait training, with gains on every measure and less freezing. Fall risk is still raised: walking while doing a second task and walking on uneven ground remain hard, and she fell once. Parkinson’s disease is progressive, so keeping these gains depends on a long-term exercise routine.
By 6 weeks: walk 10 minutes outdoors on uneven ground while counting backward, with no loss of balance; Timed Up and Go with a counting task under 13 s; independent with a written exercise program 3 times a week; start a community exercise class suited to people with Parkinson’s disease.
Continue once a week for 6 weeks, then discharge to a long-term home and community program. Skilled care is needed for dual-task and outdoor gait training and to set up a safe program she can keep up alone. Suggest a re-check in 6 to 12 months, or sooner after a fall or a change in mobility. Report sent to her neurologist.
A brief account of the period: what you did, what the patient reports, and how engaged they have been.
Avoid: Pasting in every daily note. Summarize the period in a few lines.
The tests from the evaluation, repeated the same way, set beside the baseline so the change is plain.
Avoid: Switching to a different test. Change can only be shown with the same measure, done the same way.
Each goal from the plan of care, with its baseline, its current value, and a status.
Avoid: Marking goals “progressing” report after report with no new number.
What the change means: whether the patient is responding, what still limits function, and what is in the way.
Avoid: Restating the measures. Interpret them.
New goals in place of the ones that were met, and revised goals for ones that need more time or a different target.
Avoid: Carrying unmet goals forward unchanged, with no explanation.
The decision and the reasons: continue, change the plan, or discharge.
Avoid: Asking for more visits without saying what they will achieve that a home program can’t.
If the evaluation used the LEFS and the report uses another scale, nobody can see the change. Repeat the same tests, the same way.
Write the current value next to each goal. “Progressing” means little without it.
Say what further skilled care will achieve, and why a home program alone won’t get there yet.
Record attendance. Missed visits explain slow progress and shape the next plan.
When a goal is met, set the next one, or say the patient is ready for discharge.
Vero Scribe writes the progress report in your template from the re-assessment conversation, with the patient’s consent, or from your dictation. You check the numbers, edit the goals, and export it to PDF or Word for the referrer.
At the interval your clinic, regulator, or payer sets, and whenever the patient’s status changes or the goals need revising. Many clinics schedule one every few weeks.
A progress report compares measures with the baseline and updates goal status. A re-evaluation is a fuller re-examination, usually for a new problem, a significant change, or a plan of care that needs rebuilding. Payers may treat the two differently, so check what yours requires.
Show measurable progress, name the limitations that remain, and say what further skilled care will achieve that a home program alone can’t. Then set updated goals with a time frame.
Record it plainly, look for the reason, such as missed visits, pain, or a change in health, and change the plan. If progress has stopped despite the changes, discuss discharge with a home program or a return to the referring clinician.
Yes. Copy it, or download it as a Word or text file. No account needed.
Follow-up visit note with pain, ROM, MMT, special tests, timed interventions, and the home program.
Initial evaluation with history, systems review, tests and measures, prognosis, goals, and plan of care.
Per-visit treatment log: each intervention with parameters and minutes, the response, and next steps.
End-of-care summary with initial and final measures, goals met, the home program, and follow-up.
How to write progress notes, with examples and a 12-point checklist.
PT note examples for evaluation, daily treatment, progress, and discharge.
Draft progress notes in your template, then edit and export them.
Notes, documents, and follow-up in one workspace.
The codes used most often in physical therapy.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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