Skip to main content

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 the added webpages linked below offer additional guidance specific to pediatric patients and clients when protocols and practice may differ from managing adults. These sections are identified at the end of various sections throughout this resource.

Additionally, be sure to reference the companion article, Documentation: Risk Management, for related information.

Log in or create a free account to keep reading.


Join APTA to get unlimited access to content.


You Might Also Like...

News

2025 APTA House of Delegates Motions Posted

Jun 3, 2025

APTA members can now access 48 motions that include seven proposed bylaws amendments that will be forwarded for consideration by the 2025 APTA House of

Perspective

Cancer Rehabilitation Month Champions Healing Beyond Treatment

Jun 2, 2025

Members of APTA Oncology share information and resources about Cancer Rehabilitation Month, a new public awareness campaign.

Feature

Short-Handed: Workforce Projections Predict Profession Shortages

Jun 1, 2025

A new APTA report outlines forecasts of a supply shortage of physical therapists through 2037.