Plan of Care

• Plan of care

  Outlines goals and outcomes, the intervention plan, plans for referral to or consultation with other health care professionals, and plans for the conclusion of physical therapy services
• Goals and outcomes

  State the predicted changes in the patient's ability to perform functional activities that are meaningful to the patient and participate in life roles as a result of implementing the plan of care
• Intervention plan

  Contains evidence-based interventions that address the patient's movement problems, remediate deficits, and promote activity and participation
• Developing a plan of care

  1. Shared decision-making process

  2. Outlining goals and outcomes

  3. Determining intervention plan

  4. Plans for referral and consultation

  5. Plans for conclusion of physical therapy
• Shared decision-making

  • Patient and physical therapist review patient's initially stated goals to determine if they are realistic and appropriate
  • Patient identifies realistic meaningful benchmark goals
  • Physical therapist directs patient to additional goals
  • Evidence-based options for treatment are reviewed, selected, and agreed on with the patient
• Patient-centered functional goals


  • Relate to the person's participation in relevant life roles or activities
  • Target the patient's reported concerns and participation limitations
  • Are the intermediate steps that aid the patient in meeting the final outcomes
• Writing patient-centered functional goals


  1. Specific

  2. Measurable

  3. Attainable

  4. Realistic

  5. Time-bound
• Components of a patient-centered functional goal


  • Who (the patient)
  • What (the activity the patient will perform)
  • Under what conditions
  • How well
  • By when
• Procedural interventions


  • Adaptive and assistive technology
  • Biophysical agents
  • Functional training
  • Integumentary repair or protection
  • Manual therapy
  • Motor function or movement training
  • Respiratory or ventilatory techniques
  • Therapeutic exercises
• Intervention strategies


  • Remediation
  • Compensation
  • Adaptation
  • Task modification
  • Environmental modification
  • Prevention
• Remediation strategies


  • Enhance skills and resources or reverse impairments
  • Directed toward remediating or improving the patient's status in terms of impairments, activity limitations, participation restrictions, and recovery of function
• Compensatory strategies


  • Directed toward promoting optimal function using alternative motor patterns or strategies to complete a task
  • Taken when potential for change in the body system is not possible
• Adaptation strategies


  Alter the environment or the task
• Task modification strategies

  Alter the demands of the task
• Environmental modification strategies


  Alter the demands of the environment on the patient
• Prevention strategies


  Refers to the management of anticipated problems and maintaining health
• Patient education


  • Communicates salient information, improves patient health behavior, self-efficacy, and self-management skills
  • Includes education about the current condition, specific impairments, functional limitations, or participation restrictions, plan of care, risk factors, resources, healthy lifestyles, and the need for health, wellness, or fitness programs
• Patient-centered educational strategies


  • Assessing the patient and family needs
  • Considering individual differences
  • Developing a written plan that addresses the needs of the patient
  • Providing relevant information and skills
  • Using a variety of educational tools
  • Actively engaging the patient and caregiver in the processes
  • Evaluating the learning achieved
• Elements to consider when selecting an educational approach


  • The patient's cognitive, sensory, emotional, psychological, and physical capabilities
  • The patient's stage of recovery
  • The patient's experience, beliefs, knowledge, skill, literacy level, and learning style
  • The task and the environment
• Intrinsic motivation


  • Essential in optimizing long-term adherence
  • Can be provided by a sense of connectiveness, self-efficacy, and autonomy
• Communication and coordination


  • Physical therapists share the assessment and plan of care with members of the team and provide ongoing communication on progress towards goals
  • Physical therapists consult with other disciplines and coordinate scheduling of physical therapy sessions
• Physical therapists work with all members of the team on discharge planning providing input on the patient's functional status to determine optimal date of discharge and discharge destination