Physical Therapy Documentation Guidelines

Physical therapy documentation is an important part in a physical therapist’s sessions with patients. is an important part in a physical therapist’s sessions with patients.  It is very vital to patient care that it is required by the American Physical Therapist Association (APTA) and other organization that seeks to regulate and standardized the physical therapy industry.

Below are several recommended guidelines to follow for accurate physical therapy documentation.  Following these guidelines will ensure that there is proper care of the patient and there is clear communication among the doctors who are working with the patient.  These guidelines for physical therapy documentation are also important for billing.

  • Medical history of the patient and doctor’s initial evaluation – good physical therapy documentation needs to include patient history including medications, medical conditions, injuries and surgeries the patient might have and undergone.  The initial evaluation will include necessary tests and measurements to determine the need for physical therapy.
  •  A diagnosis and a prognosis – physical therapy documentation needs to show the reason why the patient is having physical therapy, the level of physical dysfunction and mobility limitations.  The doctor’s prognosis will indicate the physical therapy approach to reach a desired outcome.  This should also include the estimated time required to achieve a certain goal.
  • A care plan – for physical therapy documentation, this is a detailed outline that indicates the specific goals, time frame of each goals, the number of physical therapy sessions needed to achieve the goal and the after discharge plan.
  • Patient visits and follow-up re-examinations – physical therapy documentation should also cover all of the patient’s visits, the exercises done during the physical therapy sessions and the patient’s medical progression.  Re-examinations and re-evaluations are important so that the doctor or the physical therapist can make changes to the treatment plan if necessary.
  • Discharge summary – this should be included in detail when completing physical therapy documentation.  A complete discharge summary will provide a detailed report on what goes on during every physical therapy session and how the patient is progressing with every session attended.  A recommended discharge summary should also include post-discharge treatment plans which physical therapy patients can do at home to prevent recurrence of medical condition.

As a physical therapist, it can be easy to miss some important notes in your physical therapy documentation.  It is a good habit to always begin each physical therapy sessions with an evaluation and a care plan in accordance with the physician’s certification or recommendation.  Progress notes must be done at the end of every session so that no details might be omitted and that the patient’s treatment plan is followed accordingly.

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