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 imortant 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

Compliance Matters

Mar 01, 2017 / Column

Documenting the new evaluation codes.

The Keys to Effective Documentation

Aug 01, 2016 / Column

Be thorough and try to think like a payer.


Related Courses and Events

View more courses and events
Course Defensible Documentation Part 2: If You were the Auditor

August 23, 2018


Standard: $169
$0 for APTA Members

APTA Membership saves you $169!

Course Defensible Documentation Part 1: Balancing Offense and Defense

December 20, 2017


Standard: $169
$0 for APTA Members

APTA Membership saves you $169!

Course Defensible Documentation: A Framework for Physical Therapy Documentation

October 19, 2017


Standard: $99
$0 for APTA Members

APTA Membership saves you $99!

Course ICD 10: Final Steps for Successful Implementation

May 12, 2017


Standard: $169
$0 for APTA Members

APTA Membership saves you $169!