Skip to main content

Documentation: Initial Examination and Evaluation

Article
Date: Friday, June 28, 2024

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.

Create a free account Log in
Share This
Resource Details

Date: June 28, 2024
Contact:  practice@apta.org
Content Type:  Article

You Might Also Like...

Khushboo Patel, PT, DPT and her father

Column

Defining Moment | When My Father's Neck Pain Became My Calling

Apr 1, 2026

How a moment in eighth grade set one clinician on the path to physical therapy.

Group of eight advocates holding orange ‘ChoosePT’ signs outdoors, with trees and the U.S. Capitol building visible in the background.

Article

From Capitol to Clinic: How APTA's Unified Advocacy Is Advancing Our Payment

Apr 1, 2026

A look at the APTA advocacy updates from the past year across three areas: federal, payer, and state.

Physical therapist measures a seated patient’s blood pressure in a clinic setting.

Article

Powering Progress in Primary Care

Apr 1, 2026

How APTA and its members are working to advance physical therapists as entry-point providers.