Physical Therapy Documentation Steps

In any medical field, documentation and record keeping is vital to track patients’ progress and also for getting reimbursed by insurance companies.   For therapist, physical therapy documentation is the health record which they keep in order to track the initial examination, progress and success of care plans for their patients.

Physical therapy documentation can be broken down into four major steps to simplify it.

The first step is the initial evaluation.  All patients need to undergo this step before proceeding to any other sessions.  This part of physical therapy documentation is normally done in a session.  Here, the therapist will study the patient’s medical history as well as evaluated the physical abilities of the patient.  Family history, medication being taken currently, past surgeries and even living environment are determined.

The therapist will evaluate the patient’s level of functionality and the patient’s current physical limitations.  Once the evaluation is completed on the physical therapy documentation, the therapist can then create a treatment plan with the goals and the techniques to be applied to reach those goals.

Also, the names of the patient, the therapist should be clearly indicated in any physical therapy documentation.  A referral from a physician should also be indicated in this section.

The second step of physical therapy documentation is the detailed recording of patient’s sessions.  Exercises performed and modalities administered are noted and progress reports should also be indicated here.  Missed or cancelled sessions should also be included in this step.

The third step is the evaluation of the patient’s progress.  This part of the physical therapy documentation will be taken at a specific time period initially agreed upon by the patient and therapist.  This evaluation period is set to gauge if the goals are met and adjustments can be made promptly if they are not met. There are cases wherein new or additional goals are set to ensure that the patient will be able to go back to pre-injury or pre-surgery functionality.

The fourth and final step is the discontinuation or discharge report.  This is a vital part of physical therapy documentation as it completes the whole process.  It summarized the therapy sessions and recommends further action if needed.  In cases of discontinuation, the reason has to be stated on this section.

It is important to comply with the physical therapy documentation requirements not only for record keeping but also for reimbursement purposes.  It is vital to establish medical necessity in the documentation to support the plan of care created for  physical therapy patients.


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