What follows is a description of the main documentation elements of patient and client management: initial examination and evaluation, visit, reexamination, and conclusion of episode of care summary.
Please note that Defensible Documentation offers additional guidance specific to pediatric patients and clients, when protocols and practice may differ from managing adults. These sections will be identified at the end of various sections throughout this resource.
These elements are taken from APTA's Guidelines: Physical Therapy Documentation of Patient/Client Management.
Table of Contents
Click on the links below to jump to items of interest.
- History (including Review of Systems), Systems Review, Tests and Measures
Plan of Care
Interventions for the Plan of Care
Conclusion Care Disposition Planning
- Selecting Outcome Tools
- Establishing a Baseline and Outcome Status
- Conclusion of Episode of Care
How to Convey Skilled Interventions in Daily Notes
How to Communicate Progression of Care and Ongoing Assessment in Daily Notes
Support for Timed Interventions
Caution: SOAP Notes and Flow Sheets
Skilled Maintenance: Demonstrating Skilled Therapy for Maintenance or Lack of Progress