By using this site, you are consenting to our use of cookies. To find out more visit our privacy policy.
Effective documentation isn't about your practice: it's part of it.
Clinical documentation of patient and client management is a professional responsibility and a legal requirement. But it's more than just a record of services provided and outcomes to support payment for services: documentation is critical to ensure that individuals receive appropriate, comprehensive, efficient, person-centered, and high-quality health care services throughout the episode of care.
The resources below are rooted in APTA Board of Directors guidelines and evidence-based best practices.
Documentation Elements
Access the main documentation elements: initial examination and evaluation, visit, reexamination, and conclusion of episode of care summary.
Setting-Specific Considerations
There are many elements of documentation that need consideration; one of the most important is clinical setting.
Risk Management
Solid documentation can demonstrate that you met or exceeded the standard care and can help you mitigate your risks.
Recommended Content
Physical therapists must be mindful of the following documentation requirements for Medicare Part B. The following summarizes the documentation requirements required under Medicare Part B. Please refer to CMS’ Medicare Benefit Policy Manual Chapter 15 Section
Many PTs find it difficult to document effectively while providing patient and client care.
Additional Documentation Content
News
The latest update comes after clarifications the insurer released last year following a set of initially burdensome policy expansions.
News
APTA members are informing key decisions in a rapidly evolving area of health care regulation.
Article
Access considerations, guidelines, tools and resources to help you with general clinical decision-making in physical therapist practice.
Column
"Documenting value-based care" simply means painting a clear picture of the good things you're doing as a PT.
Policies & Bylaws
House position: The physical therapist has oversight of all documentation regardless of the setting in which physical therapist services are provided and shall comply with jurisdictional documentation requirements.
Article
There are many elements of documentation that need consideration; one of the most important is clinical setting.