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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

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.

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.