Skip to main content

Effective documentation isn't about your practice: it's part of it.

Clinical documentation of patient and client management is a professional responsibility and a legal requirement. But it's more than just a record of services provided and outcomes to support payment for services: documentation is critical to ensure that individuals receive appropriate, comprehensive, efficient, person-centered, and high-quality health care services throughout the episode of care.

The resources below are rooted in APTA Board of Directors guidelines and evidence-based best practices.

Documentation Elements
Access the main documentation elements are: initial examination and evaluation, visit, reexamination, and conclusion of episode of care summary.

Setting-Specific Considerations
There are many elements of documentation that need consideration; one of the most important is clinical setting.

Risk Management
Solid documentation can demonstrate that you met or exceeded the standard care and can help you mitigate your risks.

Recommended Content

Medicare Part B Documentation Requirements

Apr 30, 2019 / Article

Documentation Overview

May 18, 2018 / Article

Documentation Tips

May 18, 2018 / Article

Additional Documentation Content

Informed Consent: What PTs Need To Know

Apr 1, 2021 / Column

Understand your legal obligations to your patients.

Clinical Decision-Making in Physical Therapist Practice

Sep 3, 2020 / Article

Access considerations, guidelines, tools and resources to help you with general clinical decision-making in physical therapist practice.

Documentation: Risk Management

Dec 18, 2018 / Article

Solid documentation can demonstrate that you met or exceeded the standard care and can help you mitigate your risks.

Tips for Defensible Documentation

May 7, 2019 / Article

It helps to consider two questions: Why now? And why you?

Creating a Written Portrait

Oct 1, 2018 / Column

"Documenting value-based care" simply means painting a clear picture of the good things you're doing as a PT.

Documentation Authority For Physical Therapist Services

Aug 30, 2018 / Policies & Bylaws

House position: The physical therapist has oversight of all documentation regardless of the setting in which physical therapist servicesĀ are provided and shall comply with jurisdictional documentation requirements.

Compliance Matters

Mar 1, 2017 / Column

Documenting the new evaluation codes.

The Keys to Effective Documentation

Aug 1, 2016 / Column

Be thorough and try to think like a payer.

Physical Therapy Documentation Reform

Oct 1, 2013 / Policies & Bylaws

House position: APTA shall pursue documentation standards that focus primarily on clinical reasoning and decision making in the provision of physical therapist services.