Completing the Assessment Section of IE

Completing the Assessment Section of the Initial Evaluation

*Denotes a required piece of information

The Assessment section provides an area for: 

• Objective Findings
• Narrative Problems List*
• Narrative Goals List*
• Rehab Potential*
• Therapist Assessment*

This section was built in such a way so that if you have flagged information from the Subjective and Objective sections these will be pulled down in the Objective Findings Table or Narrative Problems List. 

The Objective Findings Table provides an area for quantitative values that may be tracked throughout a Case in order to provide numerical evidence of functional gain over time.

• These Measurements will require that specific Goal Measurement be added for this table as well as an Achieve Within time frame. 

• If Measurements are Flagged in a Template, the Goal Measurement and Achieve Within time frame could be filled out and already fulfilled prior to opening a new Initial Evaluation. Then you would only modify as needed for the patient.

**Note: Any values added to this table will allow for the auto calculation of Goal Percentage in future Progress Notes/ Discharge Summary documents allowing you to save time on documentation.

• Objective Findings must be added via Flag from the Subjective and Objective sections. However, you will be able to Delete any items for the patient using the Trash icon on each row. 

The Narrative Problems and Goals List Table provides an area for written-based problems and goals for the patient. This section may be filled out via template and only require modifications as necessary per patient. 

The Validation Requirements of this section are:

• At least one Problem and one Goal are included for the Initial Evaluation. However, you may have more Problems than Goals or vice versa. 
• If a Goal has been assigned, an Achieve Within time frame has been assigned as well. 

You may add additional Problems or Goals by typing the Problem Description or Goal Description Free Text area. As you add, additional empty lines will populate below for you.

**Note: Compliance has confirmed that you can refer to the Objective Findings Table to cover a functional component of a Strength or Range of Motion Problem/ Goal for the patient.

Rehab Potential is assigned by selecting one of the options available in the drop down menu. 

Therapist Assessment may be filled out by typing in the free text area.