Physical Therapy Documentation Stages

By Nitin Chhoda PT, DPT on December 9, 2012

Nitin Chhoda explains the different stages of physical therapy documentation.  Pointing out important guidelines to follow to ensure a smooth documentation process and avoid redundancy.

physical therapy documentation stagesThe speed of physical therapy documentation with which a patient recovers with physical therapy is determined by many factors.

But one thing that physical therapists have control over is the level of care a patient gets, from one appointment to the next.

If each step isn’t documented well, the patient may end up repeating things or wasting time going over their own history with the physical therapist rather than working on getting better.

Physical therapy documentation is extremely important to the process of helping patients to recover and become stronger.

Initial Evaluations

The first stage in physical therapy documentation is the initial interview and examination of the patient. This is an incredibly important process, as it will determine the rest of the treatment plan for the patient.

Of course, the basic patient information will also be gathered and input, assuming electronic health records have not been transferred by a referring physician, as well as details about the injury or pain that the patient experienced.

Every detail is not only important, but may be vital for compliance. And the entire course of the physical therapy documentation and treatment will be determined from the current state of the patient’s health. Goals must also be established so that the progress of the patient can be measured against those goals.

SOAP and Other Details

While taking care of the patient should be the primary concern of the physical therapist, there should also be attention paid to the way the patient’s insurance company will be billed. Some insurance companies have very specific requirements for continuation of treatment and reevaluations.

Rather than risk a rejected or denied claim due to incorrect or insufficient physical therapy documentation, ensure that all physical therapists follow procedural guidelines for documenting the intake of each new patient.

SOAP, or subjective, objective, assessment, and plan, is the standard system of evaluating a new patient. This standard is important for a few reasons.

First of all, it ensures that there is a standard for all physical therapists. Second, when using SOAP, the most important parts of each initial evaluation will be included in the physical therapy documentation.

Subsequent Visits and Treatmentphysical therapy documentation phase

The actual physical therapy documentation and treatment plan should be on a realistic schedule with various stages and goals worked into the physical therapy documentation plan.

Patients are often helped greatly if they can imagine what their life will be like when they feel better. And to have some intermediary goals will keep them thinking ahead and about improvement.

And of course, each session should be well documented with details about the patient’s recovery and activities. The next session will go more smoothly if a detailed physical therapy documentation account of the current session is in the patient record.

This will help the patient to recover as quickly as possible and to make the most of their time with their physical therapist.

Conclusion of Treatment

Just because a patient is done with their treatment, doesn’t mean it’s okay to forget about physical therapy documentation protocol. The patient’s last visit does not signal the last responsibility of the physical therapist or the practice.

Discharge notes will identify what the billing staff can bill for and the information may be useful for future patients or for the management staff, so assessments can be accomplished with real data.

About Nitin Chhoda PT, DPT

Nitin Chhoda PT, DPT is the CEO of In Touch EMR and In Touch Biller Pro, an electronic medical records and medical billing software system built be leaders in the physical therapy software industry, with thousands of satisfied customers across the world. For more information, please visit www.InTouchEmr.com and www.InTouchBillerPro.com

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