In light of the importance of documentation in patient and 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 (.pdf).
Note: While it's as comprehensive as APTA can reasonably make it, Defensible Documentation cannot address every aspect of physical therapy documentation. Some specialized settings, practice arenas, regulations, and other areas may require additional types or components of documentation. Check specific compliance requirements of payers, third-party administrators, state laws, and accreditation organizations such as The Joint Commission and CARF.
If you have any questions, or feedback, please contact APTA's Practice Department at 800/999-2782, ext 3176 or by email at: firstname.lastname@example.org.
Objectives of this resource, documentation to reflect best practice, documentation for payment, and documentation for risk management and compliance.
Initial examination, visit/encounter, reexamination, discharge summary, plus information and examples of goals, skilled care, progression of care, progress reports, and more.
Information on specific documentation requirements and regulations by practice setting and how to improve documentation in various practice settings.
Information on confidentiality, incident reporting, security using EHRs, and more.
Links to published articles, APTA positions on documentation, information from CMS, and more.
Defensible Documentation Tips
Documentation Checklist Sample (.doc)