Due to the importance of documentation in patient/client care, and in response to many of the current issues related to physical therapy documentation, APTA has developed the "Defensible Documentation for Patient/Client Management" resource based on APTA's Guidelines: Physical Therapy Documentation of Patient/Client Management.
The resources below are available in Adobe PDF. Some of the longer resources begin with a "table of contents," which uses links to navigate to particular pages within the document.
If you have any questions, or feedback, please contact APTA's Practice Department at 800/999-2782, ext 3176 or by e-mail at: firstname.lastname@example.org.
- Introduction to Defensible Documentation (.pdf)
Please be aware that there will be specialized settings, practice arenas, regulations, etc. that may require other types or components of documentation that are not addressed in this resource. Please check payer, state law, and specific accreditation organization (i.e., Joint Commission, CARF, etc) requirements for compliance.
- Components of Documentation Within the Patient/Client Management Model (.pdf)
Contains initial examination, visit/encounter, reexamination, discharge summary, plus information and examples of goals, skilled care, progression of care, progress reports and more.
- Current Concerns in Physical Therapy Documentation (.pdf)
Payment initiatives, payer documentation expectations, Medicare documentation standards, and more.
- General Guidelines (.pdf)
Includes information on important elements to include in documentation.
- Improving Your Clinical Documentation: Reflecting Best Practice (.pdf)
Documenting evidence-based practice, demonstrating progress, medical necessity and skilled care, risk management are just a few of the topics covered in this document.
- Setting Specific Considerations (.pdf)
Information on specific documentation requirements and regulations by practice setting and how to improve documentation in various practice settings.
- Additional Topics in Documentation of Patient/Client Care (.pdf)
Use of abbreviations, components and maintenance of a patient/client record, how to handle denials, tips for efficient documentation are covered in this document.
- Other Considerations (.pdf)
Other considerations contains a documentation tips sheet, sample documentation review checklist and self-assessment.
- Frequently Asked Questions (.pdf)
Get answers on maintaining records, verbal orders, using forms, and more.
- Definitions and References (.pdf)
This resource covers authentication, Medicare regulations, billing and coding resources, APTA's position on documentation, documentation articles, and more.
- Appendices (.pdf)
This document contains documentation resources, documentation template, communicating skilled interventions, and medical necessity.
- Defensible Documentation: Case Examples
This page contains specific cases with examples of each type of documentation note.