Physical Therapy Documentation of Patient and Client Management

The American Physical Therapy Association (APTA) is dedicated to addressing the PT demands of society, the needs of its members, and the development and improvement of  PT art and science, including practice, teaching, and investigation. The APTA Board of Directors adopted the following standards for physical therapy documentation to fulfill these obligations.

 

It is acknowledged that these standards do not fully represent the specific documentation needs for the various specialist fields in PT. These Standards, applicable to handwritten and electronic documentation systems, are designed to serve as a basis for developing more detailed documentation guidelines in particular areas while at the same time offering advice for the PT profession in all fields of work.

 

Clinical documentation of patient and client management

Patient and client management clinical documentation is a professional obligation and a legal necessity. But the services and results for supporting payments for services are not simply records: documentation is essential to ensuring that people get enough, complete, efficient, personalized, and high-quality healthcare throughout the care episode.

The following materials are founded in APTA Board of Directors standards and best practices based on evidence.

 

Authentication:

Method to validate the completeness, accuracy, and finality of the input. Authentication indications may be used exclusively on protected electronic recording systems, including written signatures and computer signatures.

 

Elements of documentation

The key documents are initial assessment, visit, review, and end of the care summary episode.

 

Initial Examination/Evaluation

Initial encounter documentation is often referred to as the “initial review,” “initial assessment,” or “initial exam/evaluation.” The first examination/evaluation is usually done during one appointment but may occur over one visit. Documentation components for the first review/evaluation include historical data, system reviews, tests, and measurements. Evaluation: Assessment is a thinking process that cannot involve formal documentation. Documentation of the evaluation of data gathered to examine and identify patient-client management-related issues may be included.

 

Diagnosis:

Indicates the degree of disability, restriction of activities, and physical therapist involvement. Select one or more preferred patterns of practice from the Guide to Physical Therapist Practice.

 

Forecast:

Provides evidence on the expected degree of improvement which may be achieved through intervention and the time needed to achieve that level. Typically, the forecast is not a distinct documentation piece, but components are incorporated in the care plan.

 

Care plan:

generally specified contains objectives, planned interventions, suggested frequency and duration, and discharge plans. Visit/Encounter A visit or encounter record, commonly termed a progress note or daily note, chronicles sequential execution of the physical therapist’s treatment plan, including changes in the patient/client status and modifications of the particular treatments and progressions utilized. Specific plans for future visits or visits may also be included.

 

Reexamination

The reexamination documentation contains information from repeated or new examination components and is submitted for evaluation and modification or redirection of the action.

 

Discharge or Discontinuation Summary

Unload or Discontinuation Summary Documentation is needed to describe the progression towards the objectives and discharge plans after completing the current Professional Physical Therapy intervention sequence episode.

 

Setting-Specific Considerations

Many aspects of documentation need to be considered; one of the essential elements is clinical conditions.

 

Risk Management

Solid documentation may show that you have met or beyond standard treatment and can minimize your risks.

 

GENERAL GUIDELINES

• Documentation is needed for all visits • All documents must conform to relevant legal/regulatory requirements.

 

• All handwritten entries in ink and the original signatures will be included. Electronic entries must be done with adequate safeguards for security and confidentiality.

 

• Charting mistakes should be rectified by drawing a single line by error and initializing the chart and date it or using the proper electronic documentation method, demonstrating that the changes were done without deleting the original record.

 

• Appropriate identity of the patient and the physical therapist or physical therapist assistant must be included in all documents.

 

• The complete name and identity number of the patient/client must, if relevant, be provided in all official papers. o All entries have to be dated and verified with the complete name and designation of the provider.

 

• The physical therapist providing the service must authenticate the examination, assessment, diagnosis, prognosis, treatment plan, and discharge summary document.

 

• The visit/encounter intervention note documentation must be validated by the physical therapist or the service assistant.

 

• A physical therapist or physical therapist assistants or other physical therapists or physical therapist assistants authenticated by a certified physical therapist. If allowed by law, physical therapist assistant graduates may authenticate the physical therapist assistants’ documents.

 

• Student documentation in a physical therapist or Physical Therapeutic Assistant Programs (SPT/SPTA) must also be verified by the physical therapist. The physiotherapist assistant may be authenticated by a physical therapist assistant, where legislation authorizes the paperwork.

 

 

Documentation Overview

Many PTs find it hard to record correctly while delivering patient and customer service. PTs thus frequently see paperwork as expensive, irrelevant, and unjustified. The coordination, communication, and documentation procedures are essential in ensuring that people get adequate, complete, efficient, personally focused, and quality health care throughout the whole care episode. Coordination involves all parties working together. Communication is information sharing. Any documentation that indicates the treatment and services given and the individual’s reaction is any entry into the individual’s health record.