Oregon Administrative Rules
Chapter 848 - OREGON BOARD OF PHYSICAL THERAPY
Division 40 - MINIMUM STANDARDS FOR PHYSICAL THERAPY PRACTICE AND RECORDS
Section 848-040-0130 - Standards For The Documentation Of An Initial Evaluation

(1) Patient's full name, age and sex;

(2) Identification number, if appropriate;

(3) Referral source, including patient self-referral;

(4) Pertinent medical or physical therapy diagnoses, medications if not otherwise accessible in another part of the patient's medical record, history of presenting problem and current complaints and symptoms, including onset date;

(5) Prior or concurrent services related to the provision of physical therapy services;

(6) Any co-existing condition that affects either the goals or the plan of care;

(7) Precautions, special problems and contraindications;

(8) Subjective information (patient's knowledge of problem);

(9) Patient's goals (with family input or family goals, if appropriate). Goals may be as provided in an applicable IEP, IFSP, or other designated plan of care; and

(10) Appropriate objective testing results, including but not limited to: