Physical Therapists are required to document their patient care with completion of the below documentation.

1. Initial Evaluation

2. Re-Examinations

3. Visit / Encounter Notes

4. Discharge or Discontinuation

1. Initial Evaluation 

 History

Review of past and current medical and social information May include:

1. Medications
2. Previous clinical tests
3. Living environment
4. Previous level of function
5. Cultural preferences
6. Highlight pertinent information

Systems Review

1. Helps determine conditions that may impact the chief complaint
2. Can identify conditions that require consultation with other providers
3. Can be completed in a relatively short time by experienced clinicians

Tests and Measures

1. Identify the specific tests and measures used
2. Document the associated finding or outcome
3. Use standardized test and measures

Evaluation

1. A synthesis of all of the data and findings gathered from the examination
2. Collaborative decision making with the patient/client
3.  Process leads to documentation of impairments, functional limitations, and disabilities
4.  Guides the physical therapist to a diagnosis and prognosis for each patient/client

Diagnosis

1. Determined by the physical therapist after the examination and evaluation process
2. Typically made at the impairment and functional limitation levels

Prognosis

1. Conveys the physical therapist’s professional judgment for the patient’s/ client’s predicted functional outcome and the required duration of services to obtain this functional outcome.

Plan of Care (POC)

Include goals stated in functional, measurable terms that indicate the predicted level of improvement in function.

1. Collaboration with the patient/client and other appropriate stakeholders.
2. A statement of interventions/treatments to be provided during the episode of care.
3. Duration and frequency of service required to reach the goals.
4. Anticipated discharge plans (may also be part of the prognosis or written separately).

2. Re-Examinations

1. Include data from repeated or new examination elements
2. Evaluate the patient’s/client’s status and modify or redirect intervention
3.  Indications for a re-examination include new clinical findings or failure to respond to interventions

3. Visit / Encounter Notes 

Documents sequential implementation of the plan of care established by the physical therapist, including:

Changes in patient/client status variations and progressions of specific interventions used. May include specific plans for the next visit or visits Documentation is required for every visit/encounter . May include as applicable:

1. Patient/client self-report (as appropriate).
2. Identification of specific interventions provided, including frequency, intensity, and duration as appropriate. Examples include:
3. Knee extension, three sets, ten repetitions, 10# weight
4. Transfer training bed to chair with sliding board, verbal cueing and minimal assistance Equipment provided.
5. Changes in patient/client impairment, functional limitation, and disability status as they relate to the plan of care.
6. Factors that modify frequency or intensity of intervention and progression goals, including patient/client adherence to patient/client-related instructions.
7. Communication/consultation with providers/patient/client/family/ significant other.
8. Documentation to plan for ongoing provision of services for the next visit(s), which may include, but not be limited to: The interventions with objectives Progression parameters Precautions, if indicated

4. Discharge/Discontinuation

1. Required at the conclusion of services, whether due to discharge or discontinuation of physical therapy services.
2. Should summarize a patient’s/client’s progress towards goals, status at discharge and future plans for self-management.
3.  Completed by Physical Therapist