Get Patient Documentation Example 2020-2024

It is the position of the American Physical Therapy Association (APTA) that physical therapist examination, evaluation, diagnosis, and prognosis shall be documented, dated, and authenticated by the physical therapist who performs the service.

Though your physical therapy documentation may expand as a patient continues along an episode of care, general components of quality physical therapy documentation examples include: Patient details (DOB, name, physician contact information) Medical diagnosis. Past medical and PT treatment history.

As a PT myself, I know it's not uncommon to spend 20 to 30 minutes or more writing up an evaluation note after each visit. Whether you're an outpatient physical therapist or you work in home health, you might spend 1-2 hours of your workday typing notes.

The practice act, including accompanying rules or regulations, constitutes the law governing physical therapist practice within a state.

"Physical therapist assistants shall ensure that documentation for their interventions accurately reflects the nature and extent of services provided."

Though your physical therapy documentation may expand as a patient continues along an episode of care, general components of quality physical therapy documentation examples include: Patient details (DOB, name, physician contact information) Medical diagnosis. Past medical and PT treatment history.

The Standards of Ethical Conduct provide a foundation for conduct to which all physical therapist assistants shall adhere. Physical therapist assistants are guided by a set of core values (accountability, altruism, collaboration, compassion and caring, duty, excellence, integrity, and social responsibility).

"Physical therapist assistants shall ensure that documentation for their interventions accurately reflects the nature and extent of services provided."