| ID | Date | Type | Evaluation Diagnosis |
| 332 | 03-26-2026 | Physical Initial Evaluation | M62.81 |
| Physical Background History: Initial Evaluation with parent present throughout the evaluation. Parent consented to physical therapy evaluation today. Parent participated in PT evaluation to provide pertinent information for the assessment. Patient is a 15 month old female referred to physical therapy with developmental delay in Gross Motor skills. Patient was seen on March 26, 2026 for a scheduled physical therapy evaluation to assess current level of function. Patient born full term without complications throughout pregnancy. Patient was diagnosed with Laryngomalacia and was seen by ST for a period of time. Currently receiving OT services to help developmental delay.
Parental Report/Primary Concern/Goals: Parent would like to see child crawl and walk
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| Physical Background History: Initial Evaluation with parent present throughout the evaluation. Parent consented to physical therapy evaluation today. Parent participated in PT evaluation to provide pertinent information for the assessment. Patient is a 15 month old female referred to physical therapy with developmental delay in Gross Motor skills. Patient was seen on March 26, 2026 for a scheduled physical therapy evaluation to assess current level of function. Patient born full term without complications throughout pregnancy. Patient was diagnosed with Laryngomalacia and was seen by ST for a period of time. Currently receiving OT services to help developmental delay.
Parental Report/Primary Concern/Goals: Parent would like to see child crawl and walk
|
| Physical Surgical History: Endoscopy |
| Physical Medical History: 0. Laryngomalacia |
| Physical Medications: None |
| Patient/Family Education: Discussed the finding of the examination, reviewed the POC and goals with the parent. Discussed activities/strategies available to address current concerns and how to assist patient in achieving optimal developmental milestones. Parent states understanding and agrees to provide support at home in order to progress outcomes for patient. Parent provided opportunity to ask questions and all questions were answered to the parent's satisfaction. |
| Physical Problem List: |
| Physical Therapy Assessment: Child assessed using a Standardized Assessment
Clinical Observations: avoids weight bearing through knees, not crawling, limited balance in standing/wobbly
Parental Report: parent would like to see patient crawl and walk
The patient is a 15-month-old female referred to physical therapy secondary to developmental delay. She presents with significant deficits in gross motor development, including generalized weakness, limited mobility, decreased balance, impaired coordination, atypical gait mechanics, reduced activity tolerance, and decreased kinesthetic awareness. These impairments negatively impact her ability to achieve age-appropriate developmental milestones and participate in functional activities, daily routines, and age-appropriate play. Standardized testing using the PDMS-2 indicates delayed motor performance, with stationary skills at a 10-month age equivalence and locomotion skills at a 7-month age equivalence. These findings place the patient below average for her age and reflect moderate to severe delays in both simple and more complex gross motor tasks, significantly affecting her overall developmental progression.
Given the extent of these deficits, the patient demonstrates limitations in functional mobility and independence compared to age-matched peers, placing her at risk for further developmental delays and long-term functional impairments if not addressed. Skilled physical therapy services are medically necessary at this time to address identified impairments, promote strength, improve flexibility and active range of motion, enhance balance and coordination, and facilitate development of age-appropriate gross motor skills. Intervention will focus on promoting functional mobility and supporting the patient in achieving her highest level of independence and participation in daily activities, thereby optimizing overall developmental outcomes and quality of life. Patient would greatly benefit from skilled PT interventions in order to address established delays and facilitate functional independence and performance. Home programming alone is not sufficient to make the needed progress, direct one to one services are required for progress to be achieved. Results of the evaluation were reported and explained to parent(s), along w/ the diagnosis, prognosis, including the frequency, time and duration of treatment and contents of the plan of care. Family will be provided w/ a verbal report of progress noted along w/ any homework for the family as part of a home program (if applicable) at the end of every session. Parent(s) verbalized understanding of treatment plan and agreed to the initiation of skilled therapy.
Goals:
In 3 months, patient will pull to stand independently at various support surfaces using smooth, coordinated movement in 3 out of 4 opportunities, to promote lower extremity strength, motor planning, and progression toward pre-gait skills.
In 3 months, patient will transition from short sitting to standing independently from a variety of surfaces in 3 out of 4 trials, to improve balance, spatial awareness, and functional mobility during age-appropriate transitions.
In 3 months, patient will tolerate modified prone/kneeling position for 5+ consecutive minutes, 3 times per day over a 1-week period (per caregiver report), to enhance postural strength, kinesthetic awareness, and engagement in functional play.
In 6 months, patient will demonstrate independent standing balance without support for at least 10 seconds in 2 or more daily opportunities over a 1-week period, to promote static balance and participation in functional play activities.
In 6 months, patient will crawl forward in quadruped position independently across 10+ feet, in 2 out of 3 trials, to facilitate functional mobility, coordination, and overall strength.
In 6 months, patient will ambulate independently across 25+ feet, in 3 out of 4 trials, without loss of balance, to promote age-appropriate gait, dynamic balance, and independent functional mobility.
|
| Physical Therapy Recommendations: Physical Therapy: 1 time(s) a Week for 45 to 60 minute sessions |
| ID | Plan of Care |
Physical Therapy Plan of Care:
| 222 | | Plan Date: 03-26-2026 | | Physical Assessment Summary: Self Care/ADLs:
Types of Food: Good appetite; eating table foods; breast fed
Sleep Pattern/Cycle: Sleeps through the night in crib
Mobility & Transition:
Locomotion: Not pulling to stand, not crawling, walks HHA 2 handed
Complicating/Personal Factors Affecting the Plan of Care:
Mechanism of injury/ Illness: During check up - doctor talked to mom about therapy
Multiple Treatment Areas: Weakness, decreased balance, limited mobility
Patient age: 15 months
Rehab Potential: Good
Time since onset of injury/illness: About 4 months ago
Medical History Review:
High Complexity: The patient has a history of present problem with a history of 3 or more factors and/or comorbidities that impact the plan of care.
Assessment:
Child assessed using a Standardized Assessment
Clinical Observations: avoids weight bearing through knees, not crawling, limited balance in standing/wobbly
Parental Report: parent would like to see patient crawl and walk
The patient is a 15-month-old female referred to physical therapy secondary to developmental delay. She presents with significant deficits in gross motor development, including generalized weakness, limited mobility, decreased balance, impaired coordination, atypical gait mechanics, reduced activity tolerance, and decreased kinesthetic awareness. These impairments negatively impact her ability to achieve age-appropriate developmental milestones and participate in functional activities, daily routines, and age-appropriate play. Standardized testing using the PDMS-2 indicates delayed motor performance, with stationary skills at a 10-month age equivalence and locomotion skills at a 7-month age equivalence. These findings place the patient below average for her age and reflect moderate to severe delays in both simple and more complex gross motor tasks, significantly affecting her overall developmental progression.
Given the extent of these deficits, the patient demonstrates limitations in functional mobility and independence compared to age-matched peers, placing her at risk for further developmental delays and long-term functional impairments if not addressed. Skilled physical therapy services are medically necessary at this time to address identified impairments, promote strength, improve flexibility and active range of motion, enhance balance and coordination, and facilitate development of age-appropriate gross motor skills. Intervention will focus on promoting functional mobility and supporting the patient in achieving her highest level of independence and participation in daily activities, thereby optimizing overall developmental outcomes and quality of life. Patient would greatly benefit from skilled PT interventions in order to address established delays and facilitate functional independence and performance. Home programming alone is not sufficient to make the needed progress, direct one to one services are required for progress to be achieved. Results of the evaluation were reported and explained to parent(s), along w/ the diagnosis, prognosis, including the frequency, time and duration of treatment and contents of the plan of care. Family will be provided w/ a verbal report of progress noted along w/ any homework for the family as part of a home program (if applicable) at the end of every session. Parent(s) verbalized understanding of treatment plan and agreed to the initiation of skilled therapy. | | Physical Rehabilitation Potential: Good. with consistent Physical Therapy and parental support | | Physical Treatment Plan: | | Physical Long Term Goals: | | Category | Goal Description | | In 6 months, patient will demonstrate independent standing balance without support for at least 10 seconds in 2 or more daily opportunities over a 1-week period, to promote static balance and participation in functional play activities. | | In 6 months, patient will crawl forward in quadruped position independently across 10+ feet, in 2 out of 3 trials, to facilitate functional mobility, coordination, and overall strength. | | In 6 months, patient will ambulate independently across 25+ feet, in 3 out of 4 trials, without loss of balance, to promote age-appropriate gait, dynamic balance, and independent functional mobility. |
| | Physical Short Term Goals: | | Category | Goal Description | | In 3 months, patient will tolerate modified prone/kneeling position for 5+ consecutive minutes, 3 times per day over a 1-week period (per caregiver report), to enhance postural strength, kinesthetic awareness, and engagement in functional play. | | In 3 months, patient will transition from short sitting to standing independently from a variety of surfaces in 3 out of 4 trials, to improve balance, spatial awareness, and functional mobility during age-appropriate transitions. | | In 3 months, patient will pull to stand independently at various support surfaces using smooth, coordinated movement in 3 out of 4 opportunities, to promote lower extremity strength, motor planning, and progression toward pre-gait skills. |
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| Date | Posted By | Message |
| 03-19-2026 02:05 PM | Dolly Molina | Good afternoon,
My name is Dolly Molina, and I am the physical therapist at New Beginnings. I am reaching out to schedule a Physical Therapy Evaluation appointment with you. I am available on March 20, 2026 at 10:00 AM, and I hope this time works for you.
Please let me know if you are available at that time or if we need to find an alternative appointment.
Thank you,
Dolly Molina PT MPT
Physical Therapist
New Beginnings |
| 03-19-2026 02:06 PM | Josephine Gagliardo | Josephine (Prim) Replied: Hello. We are out of town until Monday for spring break. I apologize! |
| 03-19-2026 02:06 PM | Dolly Molina | Hi, I received your message but am not at work at the moment. Please be patient and I will respond just as soon as I can. Thank you for understanding! 😊 -- This is an automated message. |
| 03-19-2026 02:07 PM | Dolly Molina | Oh no worries. That is Ok. I can set something up for next week. Will that work for you? |
| 03-19-2026 02:07 PM | Josephine Gagliardo | Josephine (Prim) Replied: Certainly. I do work during the week. What day/time are you available? |
| 03-19-2026 02:07 PM | Dolly Molina | Hi, I received your message but am not at work at the moment. Please be patient and I will respond just as soon as I can. Thank you for understanding! 😊 -- This is an automated message. |
| 03-19-2026 02:09 PM | Dolly Molina | I have 3/26/26 at 8:00 am available |
| 03-19-2026 02:10 PM | Josephine Gagliardo | Josephine (Prim) Replied: That won't work either. I'm sorry! Is it possible to be seen on a Monday? Or Thursday or Friday after 4 pm? |
| 03-19-2026 02:10 PM | Dolly Molina | Hi, I received your message but am not at work at the moment. Please be patient and I will respond just as soon as I can. Thank you for understanding! 😊 -- This is an automated message. |
| 03-19-2026 02:17 PM | Josephine Gagliardo | Josephine (Prim) Replied: How long will the appointment be? 1 hour? |
| 03-19-2026 02:17 PM | Dolly Molina | Hi, I received your message but am not at work at the moment. Please be patient and I will respond just as soon as I can. Thank you for understanding! 😊 -- This is an automated message. |
| 03-19-2026 02:17 PM | Dolly Molina | My availability at New Beginnings is currently limited to Tuesdays and Thursday mornings due to my schedule at other facilities. After the initial PT evaluation is completed, future appointments can be scheduled with our full-time PT team, which will allow for greater flexibility and later appointment times. |
| 03-19-2026 02:18 PM | Dolly Molina | Yes the PT evaluation takes 1 hour
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| 03-19-2026 02:18 PM | Josephine Gagliardo | Josephine (Prim) Replied: Let's schedule the 3/26 at 8 am. I will arrange my work schedule accordingly. What is the address for this location? We are typically seen at the Rich Beem location. |
| 03-19-2026 02:18 PM | Dolly Molina | Hi, I received your message but am not at work at the moment. Please be patient and I will respond just as soon as I can. Thank you for understanding! 😊 -- This is an automated message. |
| 03-19-2026 02:24 PM | Dolly Molina | Thank you for your flexibility in adjusting your schedule to complete this PT evaluation. the PT office is at 1510 Zaragosa Building B-1. When you enter the drive way to the business offices you will continue on the path until it almost dead ends - then you will see signage that says Building B. You will turn to the right. If you go left you will enter parking lot for the main New Beginnings office. The PT building is at the end of a long row of office spaces. Continue to the end of the row just past a window tint shop. |
| 03-19-2026 02:25 PM | Dolly Molina | I have your appointment set on my calendar. Thank you and I look forward to meeting you both. |
| 03-19-2026 02:25 PM | Josephine Gagliardo | Josephine (Prim) Replied: Thank you! |
| 03-19-2026 02:25 PM | Dolly Molina | Hi, I received your message but am not at work at the moment. Please be patient and I will respond just as soon as I can. Thank you for understanding! 😊 -- This is an automated message. |
| 03-19-2026 02:30 PM | Dolly Molina | My pleasure
|
| 03-25-2026 06:30 PM | Dolly Molina | Hi, this is a just a reminder that Josephine has a Physical Therapy Evaluation appointment scheduled tomorrow at 08:00 AM. See you soon! - New Beginnings 🙂 |
| 03-26-2026 07:45 AM | Dolly Molina | Josephine Gagliardo : Time to check in at New Beginnings 🙂 Click here https://patient.newbeginnings-elp.com/checkin/default.aspx?AppId=910352 |
| 03-26-2026 07:45 AM | Josephine Gagliardo | Josephine is RUNNING LATE for:
8:00AM-3/26/2026
97163: PT Evaluation |
| 03-26-2026 07:57 AM | Dolly Molina | Hi, this is a just a reminder that Josephine has a Physical Therapy Evaluation appointment scheduled today at 08:00 AM. See you soon! - New Beginnings 🙂 |
| 03-26-2026 07:57 AM | Josephine Gagliardo | Josephine (Prim) Replied: Thank you! We are on our way. Traffic is heavy. Our ETA is 8:07 |
| 03-26-2026 07:57 AM | Dolly Molina | Hi, I received your message but am not at work at the moment. Please be patient and I will respond just as soon as I can. Thank you for understanding! 😊 -- This is an automated message. |
| 03-26-2026 08:00 AM | Dolly Molina | Be careful. I am here. |
| 03-26-2026 08:02 AM | Dolly Molina | 1510 Zaragosa Building B-1. It is in opposite direction of main office. |
| 03-26-2026 08:03 AM | Dolly Molina | Upon entering the driveway to the business offices behind Ernie’s Cafe Restaurant, continue straight ahead until the road nearly dead ends. Look for the rock sign stating Building B. You will turn RIGHT. Turning left will take you to the main New Beginnings office parking lot. The physical therapy office is located to the RIGHT on the corner at the very end of the row of Building B offices, just past the window tint shop.
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| 03-26-2026 08:06 AM | Josephine Gagliardo | Josephine (Prim) Replied: I think we are here! |
| 03-26-2026 08:06 AM | Dolly Molina | Hi, I received your message but am not at work at the moment. Please be patient and I will respond just as soon as I can. Thank you for understanding! 😊 -- This is an automated message. |
| 03-26-2026 02:48 PM | Matthew Martinez | Hello Josephine, this is Matthew — I’m part of the full-time PT team here at New Beginnings. Dolly shared that a twice-per-week schedule would be most beneficial for you and that Fridays tend to work best. I currently have openings next Friday (04/03) at 10:00 AM or 11:00 AM. Please let me know if either time works well for you — Matt |
| 03-26-2026 02:56 PM | Josephine Gagliardo | Josephine (Prim) Replied: Hi there! Mondays actually work best for me. I apologize for the confusion! |
| 03-26-2026 02:56 PM | Josephine Gagliardo | Josephine (Prim) Replied: She had almost mentioned that once per week is what was being recommended. Has this changed? |
| 03-26-2026 03:16 PM | Matthew Martinez | My apologies, lets stick with what Dolly recommended. Sorry for the confusion. Let me know if there is anything I can do to help.
Best,
Matt |