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Never include patient-identifying information in your prompts — Before pasting anything into Claude, remove the patient's name, date of birth, medical record number, and any other PHI. Use de-identified clinical data only: age, diagnosis, and measurements are acceptable; names and chart numbers are not. Claude is not a HIPAA-covered platform, so protect your patient's privacy at every step.
Feed Claude your actual evaluation data, not summaries — "ROM is limited" gives you a generic goal. "Shoulder flexion AROM 88 degrees, abduction 72 degrees, ER 18 degrees" gives you a precise, measurable goal tied to specific functional thresholds. The more specific your input, the more clinically useful the output.
Specify the payer context for documentation-sensitive tasks — Medicare, Medicaid, commercial PPO, and workers' compensation each have different documentation expectations. Including a line like "This patient has Medicare Part B — use medical necessity language consistent with the MAC LCD for outpatient PT" helps Claude align its output with the right standards.
Use Claude to draft, then apply your clinical judgment — Claude is excellent at structuring documentation and generating plausible clinical language, but it cannot examine your patient. Always compare the AI's output against what you actually observed, measured, and decided in the clinic. If a goal seems too aggressive or a clinical reasoning statement does not match your actual thought process, revise it.
Leverage Claude for goal-writing consistency across your caseload — One of the hardest parts of goal-writing is maintaining consistent formatting and measurability across dozens of patients. By using the same prompt template for every evaluation, you create a uniform documentation standard that makes audits, re-authorizations, and peer reviews smoother for everyone involved.
Physical Therapy SOAP Note Prompts
Home Exercise Program Prompts for PTs
Claude CoWork for Physical Therapists
ClaudePhysical TherapyBeginnerPrompt Pack
5 Claude Prompts for Treatment Planning — Physical Therapists
Ready-to-use Claude prompts for writing SMART functional goals, treatment plans, and clinical reasoning documentation.
Why Use AI for Treatment Planning?
Treatment planning is where clinical reasoning meets documentation, and it is often where PTs spend the most mental energy. Writing SMART functional goals that are truly measurable, drafting a plan of care that justifies your intervention choices, and articulating your clinical reasoning in a way that satisfies both your professional standards and payer requirements — these tasks demand precision and time that is hard to find between patients.
Claude can serve as a documentation co-pilot for treatment planning tasks. You provide the clinical data — your examination findings, the patient's functional deficits, the interventions you plan to use — and Claude structures it into the formatted documentation your EMR, your supervisor, or your payer expects. It does not replace your clinical judgment; it accelerates the process of translating that judgment into written form.
These five prompts address the core treatment planning documentation tasks: writing SMART functional goals from evaluation findings, drafting a comprehensive plan of care, articulating clinical reasoning narratives, justifying treatment modifications, and summarizing functional outcomes at key decision points. Each prompt is designed to produce output that aligns with current documentation standards and payer expectations.
The Prompts
Prompt 1: SMART Functional Goals from Evaluation Findings
Use this after an initial evaluation to generate measurable, functional, payer-ready goals.
You are a physical therapy goal-writing specialist. Generate SMART functional goals based on the following evaluation findings. Each goal must be Specific, Measurable, Achievable, Relevant, and Time-bound, and must tie directly to a functional activity the patient needs to perform.
Evaluation summary:
- Diagnosis: [e.g., R frozen shoulder (adhesive capsulitis), ICD-10 M75.01]
- Key impairments:
- [e.g., R shoulder flexion AROM 88°, abduction 72°, ER 18°]
- [e.g., R shoulder strength: flexion 3+/5, ER 3/5]
- [e.g., Pain 7/10 with overhead reaching]
- Functional limitations:
- [e.g., unable to reach top shelf in kitchen (requires ~140° flexion)]
- [e.g., unable to fasten bra or tuck in shirt behind back (requires ~45° IR)]
- [e.g., cannot lift >5 lbs above shoulder height — job requires lifting 15 lbs to shelf]
- Standardized outcome measure: [e.g., QuickDASH score: 62/100]
- Anticipated plan of care duration: [e.g., 10 weeks, 2x/week]
Instructions:
- Write 4-5 SMART goals in standard PT goal format
- Each goal must reference a specific functional task, not just an impairment
- Include a target timeframe (e.g., "within 8 weeks" or "by visit 16")
- Include measurable criteria (degrees, reps, distance, outcome score, or independence level)
- Write one goal tied to the standardized outcome measure
- Ensure goals represent a realistic but meaningful improvement from baseline
- Format example: "Patient will independently reach overhead cupboard (shoulder flexion >140°) to retrieve a 5 lb object without pain within 8 weeks to enable independent meal preparation."Example Output:
SMART Functional Goals — R Frozen Shoulder (M75.01)
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Goal 1: Patient will independently reach into an overhead cupboard (requiring shoulder flexion greater than 140 degrees) to retrieve a 5 lb object without reports of pain within 8 weeks to enable independent meal preparation at home. (Baseline: flexion 88 degrees, pain 7/10 with overhead reaching.)
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Goal 2: Patient will independently fasten clothing behind back (requiring internal rotation greater than 45 degrees) within 10 weeks to restore independence with dressing. (Baseline: IR insufficient for fastening, patient requires adaptive device.)
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Goal 3: Patient will lift 15 lbs from counter to shelf at shoulder height with R UE, rated 0/10 pain, within 10 weeks to meet occupational lifting requirements. (Baseline: unable to lift greater than 5 lbs above shoulder, R shoulder flexion strength 3+/5.)
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Goal 4: Patient will demonstrate R shoulder ER AROM of 40 degrees or greater and ER strength of 4/5 within 8 weeks to support safe overhead reaching mechanics. (Baseline: ER AROM 18 degrees, ER strength 3/5.)
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Goal 5: Patient will achieve a QuickDASH score of 30/100 or below within 10 weeks, reflecting meaningful reduction in self-reported upper extremity disability. (Baseline: QuickDASH 62/100. MCID for QuickDASH: 8-12 points.)
Prompt 2: Plan of Care Documentation
For drafting a complete plan of care that links impairments to interventions and justifies visit frequency.
You are a physical therapy documentation specialist. Write a comprehensive plan of care based on the following evaluation findings. The plan must clearly link each identified deficit to a specific intervention approach and justify the proposed visit frequency and duration.
Patient overview:
- Diagnosis: [e.g., chronic low back pain with lumbar radiculopathy, ICD-10 M54.41]
- Onset: [e.g., insidious onset 4 months ago, worsening over past 6 weeks]
- Prior treatment: [e.g., chiropractic x6 visits — minimal improvement, currently taking NSAIDs]
- Patient goals: [e.g., return to full-time nursing job requiring lifting up to 35 lbs, stand for 8-hour shifts]
Key deficits identified:
- [e.g., lumbar flexion ROM 40% of normal, extension limited by pain]
- [e.g., core stability: unable to hold plank >8 seconds, poor transverse abdominis activation on palpation]
- [e.g., R SLR positive at 42°, reproduction of radicular symptoms to posterior thigh]
- [e.g., Oswestry Disability Index: 48% (severe disability)]
- [e.g., unable to sit >15 minutes, stand >20 minutes, lift >10 lbs from floor]
Proposed plan:
- Frequency/duration: [e.g., 2x/week for 8 weeks, then reassess]
- CPT codes anticipated: [e.g., 97110, 97140, 97530, 97112, 97542]
Instructions:
- Organize into Problem List, Goals (reference Prompt 1 output or write new), Intervention Plan, and Frequency Justification sections
- For each intervention category, explain what deficit it addresses and why skilled PT is required
- Include a brief discharge criteria statement (what the patient needs to achieve for discharge)
- Justify visit frequency by referencing the severity of deficits and expected recovery timeline
- Reference relevant clinical practice guidelines if applicable (e.g., "APTA CPG for low back pain recommends...")
- Keep under 400 wordsExample Output:
Plan of Care — Chronic Low Back Pain with Lumbar Radiculopathy (M54.41)
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Problem List:
1. Lumbar flexion ROM limited to 40% of normal with pain-limited extension
2. Core stability deficit — unable to hold plank beyond 8 seconds, poor transverse abdominis activation
3. R SLR positive at 42 degrees with radicular symptoms to posterior thigh
4. Severe functional limitations: sitting tolerance less than 15 minutes, standing tolerance less than 20 minutes, unable to lift more than 10 lbs from floor
5. Oswestry Disability Index 48% (severe disability)
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Goals: (1) Patient will sit for 45 minutes continuously to tolerate a full work shift task cycle within 8 weeks. (2) Patient will lift 35 lbs from floor to waist using proper body mechanics without symptom reproduction within 12 weeks. (3) Patient will achieve an Oswestry score below 20% within 12 weeks. (4) Patient will stand for 60 minutes continuously to meet nursing job demands within 10 weeks.
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Intervention Plan:
- Therapeutic Exercise (97110): Progressive core stabilization program targeting transverse abdominis and multifidus activation to address lumbar instability. Skilled PT is required for motor control retraining and load progression.
- Manual Therapy (97140): Lumbar joint mobilization and neural mobilization to reduce radicular irritation and improve extensibility. SLR positive at 42 degrees requires skilled neurodynamic technique.
- Functional Activities (97530): Graded lifting, sit-to-stand, and prolonged posture training to restore occupational capacity. Skilled cueing required for movement pattern correction.
- Neuromuscular Re-education (97112): Lumbopelvic motor control training to address the dissociation between global and local stabilizers.
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Frequency Justification: 2x/week for 8 weeks. The severity of deficits (Oswestry 48%, positive SLR, inability to sit more than 15 minutes) and the patient's occupational demands (full-time nursing, 35 lb lifting, 8-hour standing shifts) warrant intensive skilled intervention. Reassessment at week 8 to determine need for continued care or transition to independent program.
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Discharge Criteria: Oswestry below 20%, negative SLR bilaterally, return to full-duty nursing with 35 lb lifting capacity, and patient-demonstrated independence with home exercise program.
Prompt 3: Clinical Reasoning Narrative
For documenting the thought process behind your treatment approach — useful for complex cases, students, or payer justification.
You are a physical therapy clinical reasoning specialist. Write a clinical reasoning narrative that explains the rationale behind the treatment approach for the following patient. This narrative should demonstrate skilled decision-making and justify why this patient requires one-on-one PT intervention rather than a standard home program or group approach.
Case presentation:
- Patient: [e.g., 45-year-old female, high school teacher, 12 weeks post-op R rotator cuff repair (medium tear, supraspinatus)]
- Complicating factors: [e.g., Type 2 diabetes (delayed healing), BMI 34, history of adhesive capsulitis on L shoulder 3 years ago, high anxiety about re-tear]
- Current status: [e.g., transitioning from Phase 2 to Phase 3 of rehab protocol, AROM flexion 128°, ER at side 32°, strength not yet tested per protocol, unable to write on whiteboard or carry textbooks]
- Treatment approach chosen: [e.g., prioritizing end-range AAROM with low-load long-duration stretching over aggressive mobilization due to adhesive capsulitis history; delaying strengthening entry by 1 week due to diabetes healing concerns; incorporating graded motor imagery to address kinesiophobia]
Instructions:
- Write in first-person narrative format as if the treating PT is documenting their reasoning
- Explain why this patient's case is more complex than a standard rotator cuff repair
- For each complicating factor, describe how it influenced a specific treatment decision
- Address why skilled PT is required (what would go wrong with unsupervised exercise alone)
- Reference evidence-based rationale where relevant (e.g., "Literature supports delayed loading in diabetic patients due to...")
- Keep to 250-350 words
- Maintain a professional, clinical tone suitable for peer review or payer auditExample Output:
Clinical Reasoning Narrative
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This patient presents as a more complex rotator cuff repair case than a standard post-surgical protocol would suggest, and I have made several treatment decisions that warrant documentation.
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First, this patient has a history of adhesive capsulitis in the contralateral shoulder three years ago. Research indicates that a history of adhesive capsulitis significantly increases the risk of developing stiffness in a surgically repaired shoulder. For this reason, I am prioritizing end-range active-assisted ROM with low-load, long-duration stretching rather than aggressive passive mobilization. Overly aggressive early mobilization in a stiffness-prone shoulder risks triggering a capsular inflammatory response, while insufficient ROM work risks allowing adhesions to form. This balance requires ongoing clinical assessment that cannot be replicated in an unsupervised home program.
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Second, the patient's Type 2 diabetes introduces healing timeline concerns. Literature supports that collagen maturation and tendon-to-bone integration are delayed in diabetic patients due to altered growth factor expression and vascular compromise. I have elected to delay entry into Phase 3 strengthening by one week beyond the standard protocol timeline to reduce the risk of repair failure during the critical biological healing window.
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Third, the patient demonstrates significant kinesiophobia — she is highly anxious about re-tearing the repair. This fear-avoidance behavior is limiting her willingness to push into end-range motion and is restricting her functional progress. I have incorporated graded motor imagery and mirror therapy techniques to address the cortical component of her movement limitation. Left unaddressed, kinesiophobia is a well-established predictor of poor outcomes following rotator cuff repair.
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Without skilled one-on-one PT, this patient faces the converging risks of post-surgical adhesive capsulitis, delayed healing from diabetes, and self-limiting movement patterns from fear-avoidance — any one of which could compromise her surgical outcome.
Prompt 4: Treatment Modification Justification
For documenting why you changed the treatment plan mid-episode — a common audit trigger that requires clear reasoning.
You are a physical therapy documentation specialist. Write a treatment modification justification note explaining why the plan of care is being changed. Treatment plan changes are a common audit flag, so this note must clearly document the clinical reasoning and demonstrate continued medical necessity.
Original plan:
- Diagnosis: [e.g., L knee total arthroplasty, 3 weeks post-op]
- Original frequency: [e.g., 3x/week for 4 weeks, then 2x/week for 4 weeks]
- Original focus: [e.g., ROM restoration, quad strengthening, gait training, stair negotiation]
What changed:
- New finding or event: [e.g., patient developed wound dehiscence at incision site at week 2, surgeon placed on non-weight-bearing for 10 days; OR patient reported new onset contralateral hip pain limiting exercise tolerance; OR progress has exceeded expectations and frequency can be reduced]
- Date of change: [date]
- New plan: [e.g., reduce to 2x/week, shift focus to seated ROM and quad sets only, defer gait training until WB status cleared; OR add hip assessment and modify program to address bilateral lower extremity; OR reduce to 1x/week and advance to community re-integration focus]
Instructions:
- Open with a clear statement of what changed and when
- Explain the clinical reasoning — why the original plan is no longer appropriate
- Document any communication with the referring physician or surgeon
- State the revised plan including frequency, duration, and intervention focus
- Affirm continued medical necessity or, if appropriate, document readiness for discharge
- Reference any updated objective measurements that support the change
- Keep under 250 wordsExample Output:
Treatment Modification Justification — L Knee Total Arthroplasty
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Date of Modification: February 14, 2026
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What Changed: At week 2 of the post-operative rehabilitation program, the patient developed wound dehiscence at the surgical incision site. The orthopedic surgeon evaluated the wound on February 13 and placed the patient on non-weight-bearing status for 10 days with a follow-up scheduled for February 23.
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Clinical Reasoning: The original plan of care called for 3x/week visits focused on progressive ROM restoration, quad strengthening, gait training, and stair negotiation. Weight-bearing activities — including standing exercises, gait training, and stair practice — comprised approximately 60% of each treatment session. With the non-weight-bearing restriction, continuing the current plan as written is not clinically appropriate and could compromise wound healing.
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Communication with Surgeon: Dr. M. Chen was contacted on February 13. Verbal orders received to continue PT at reduced frequency with non-weight-bearing restrictions. Surgeon will reassess wound and weight-bearing status on February 23.
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Revised Plan: Frequency reduced from 3x/week to 2x/week for the next two weeks. Sessions will focus on seated and supine ROM (target: 0-100 degrees flexion), quad sets, straight leg raises, and upper body conditioning to maintain cardiovascular fitness. Gait training and stair negotiation are deferred until weight-bearing status is cleared.
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Continued Medical Necessity: The patient's L knee flexion is currently 72 degrees (goal: 120 degrees) and a 5-degree extension lag persists. Skilled PT remains medically necessary to restore ROM, prevent arthrofibrosis, and progress this patient toward functional independence once weight-bearing resumes.
Prompt 5: Functional Outcome Summary
For summarizing where a patient stands at a key decision point — re-authorization, physician update, case conference, or discharge planning.
You are a physical therapy documentation specialist. Write a functional outcome summary for a patient at a key decision point in their episode of care. This summary should give any reader — physician, case manager, insurance reviewer, or another therapist — a clear picture of where the patient started, where they are now, and what comes next.
Decision point: [e.g., re-authorization request at visit 12 / physician progress update / case conference / pre-discharge summary]
Patient overview:
- Diagnosis: [e.g., CVA L MCA, 8 weeks post-onset, R hemiparesis]
- Setting: [e.g., outpatient neuro rehab]
Functional timeline:
- Baseline (evaluation): [e.g., Mod A for transfers, supervision for gait with hemi-walker 50 ft, unable to use R UE for any ADLs, FIM mobility score 3]
- Midpoint (visit 8): [e.g., CGA for transfers, gait with SPC 150 ft + supervision, R UE gross grasp emerging, FIM mobility score 4]
- Current (visit 12): [e.g., supervision for transfers, gait with SPC 300 ft modified independent, R UE can hold light objects, FIM mobility score 5]
Standardized measures:
- [e.g., 10MWT: 0.4 m/s → 0.6 m/s (community ambulation threshold: 0.8 m/s)]
- [e.g., Berg Balance Scale: 28 → 39 (fall risk cutoff: 45)]
- [e.g., Action Research Arm Test: 12 → 24 (functional use threshold: 32)]
Goals status:
- [Goal 1]: [met / progressing / revised]
- [Goal 2]: [met / progressing / revised]
- [Goal 3]: [met / progressing / revised]
Recommendation: [e.g., request 12 additional visits to target community ambulation speed and R UE functional use for bilateral ADLs]
Instructions:
- Present the functional trajectory as a clear progression narrative
- Use the standardized measures to anchor progress claims with objective data
- For each measure, note the clinically meaningful threshold the patient is working toward
- State your recommendation with specific rationale
- If requesting continued care, articulate what functional milestones are realistically achievable
- Keep under 350 wordsExample Output:
Functional Outcome Summary — Re-Authorization Request at Visit 12
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Patient: 58-year-old male, L MCA CVA 8 weeks post-onset with R hemiparesis, currently receiving outpatient neuro rehab.
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Functional Progression:
This patient has demonstrated consistent, measurable functional gains across all domains since initiating outpatient PT. At evaluation, he required moderate assistance for sit-to-stand transfers and could ambulate only 50 feet with a hemi-walker under supervision. His R upper extremity had no functional use, and his FIM mobility score was 3.
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By visit 8, transfers improved to contact guard assist. Gait progressed to 150 feet with a small base quad cane under supervision, and emerging gross grasp was noted in the R hand. FIM mobility improved to 4.
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At the current visit 12, the patient performs transfers with supervision only. He ambulates 300 feet with the quad cane at a modified independent level. R UE can now hold light objects (cup, utensil). FIM mobility score is 5.
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Standardized Outcome Measures:
- 10-Meter Walk Test: 0.4 m/s at evaluation, now 0.6 m/s. Community ambulation threshold is 0.8 m/s — patient is 75% of the way to this milestone.
- Berg Balance Scale: 28 at evaluation, now 39. Fall risk cutoff is 45 — patient needs 6 more points to exit the high fall-risk category.
- Action Research Arm Test: 12 at evaluation, now 24. Functional use threshold is 32 — patient is trending toward meaningful R UE function.
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Goals Status: (1) Transfer independence: progressing. (2) Community-distance ambulation: progressing. (3) R UE functional use for bilateral ADLs: progressing.
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Recommendation: I am requesting 12 additional visits (2x/week for 6 weeks). The patient's improvement trajectory across all measures is consistent and clinically significant. He is within realistic reach of community ambulation speed (0.2 m/s needed), fall-risk reduction (6 points needed on Berg), and functional R UE use (8 points needed on ARAT). Discontinuing skilled PT at this stage would leave the patient below critical functional thresholds for safe community participation.