Skip to main content

The initial physical therapist visit consists of an examination and evaluation. Typically, these are completed in one visit, but they may occur over two or more visits.

Documentation elements for the initial examination and evaluation include the following: history (including review of systems), physical examination, tests and measures, diagnosis, prognosis, management plan, and plan of care.

chart.png

Log in or create a free account to keep reading.


Join APTA to get unlimited access to content.


You Might Also Like...

Article

Payment Advocacy Takes Center Stage During APTA Capitol Hill Day

May 5, 2026

APTA members gather in front of the U.S. Capitol during APTA Capitol Hill Day. More than 250 APTA members came to Washington, D.C., with a shared message

Article

CMS Finalizes 2027 Medicare Advantage Rule: What Physical Therapists Should Know

May 5, 2026

The Centers for Medicare & Medicaid Services has released its Medicare Advantage Contract Year 2027 Final Rule, finalizing policies related to utilization

Article

Physical Therapy in the News: April 2026

May 5, 2026

"Physical Therapy in the News" is a monthly series that highlights recent media coverage of the profession and APTA members.