Initial PT/OT Evaluations
Key points to know for your initial therapy evaluation.
Most Initial Evaluations require approximately 75-90 minutes and should be scheduled accordingly. This time typically includes:
Review of referral information and medical history
Completion of the clinical evaluation
Discussion of findings with the patient and/or caregiver
Development and review of the Plan of Care (POC)
Patient and caregiver education
Initiation of therapeutic interventions
Scheduling of future appointments
Important: Patients covered by UnitedHealthcare (UHC) are generally limited to a 60-minute evaluation visit based on payer requirements. Therapists should adjust evaluation activities accordingly while ensuring all required documentation and patient education are completed.
Required Equipment and Supplies
At a minimum, therapists should have the following items available for every Initial Evaluation:
Patient Forms
Access to the Patient Authorization and Informed Consent (Intake Package)
Printed copies when electronic completion is not feasible
Personal Protective Equipment (PPE)
Gloves, Face mask, and alcohol-based hand sanitizer. Consider purchasing and keeping an emergency exposure kit for yourself.
Clinical Equipment
A blood pressure cuff and gait belt are required, and a pulse oximeter is recommended.
Many therapists also bring additional assessment tools, weights, balance pads, and other equipment. Feel free to reach out with any questions.
Scheduling Future Visits
Before leaving the patient's home or clinic, schedule the patient's next appointment whenever possible. LifeCare follows a 3-Week Supervisory Rule, meaning the evaluating therapist should have a supervisory visit with the patient at least once every three weeks, regardless of the treatment frequency assigned to a PTA or COTA.
Effective scheduling helps ensure:
Continuity of care
Compliance with supervisory requirements
Timely communication among the care team
Communication with PTAs and COTAs
When a therapy assistant will be involved in the patient's care, timely communication is essential. Following completion of the Initial Evaluation:
Notify the assigned PTA or COTA that you have completed the evaluation.
Communicate the Plan of Care, goals, precautions, and treatment focus.
Discuss any significant findings, safety concerns, or patient preferences.
Document and communicate through HUCU when appropriate.
Many therapists find it helpful to include the assistant in the conversation at the patient's home so both the patient and assistant understand the treatment plan from the start.
Coding and documentation will be reviewed in separate modules.