Documentation of a visit, often called a daily note or treatment note, documents sequential implementation of the physical therapist plan of care.
It includes changes in the individual's status; a description and progressions of specific interventions used, which may be documented in a legible flowsheet format (see Caution: SOAP Notes and Flowsheets); and communication among providers. Documentation also may include specific plans for the next visit or visits.
Either the PT or PTA may provide documentation, depending on who provided the services (see Supervision and Teamwork of a PTA). Administrative or support personnel can document administrative information such as schedule changes or authorization updates in a record or chart. In addition, support personnel may be able to assist a physical therapist in recording information in a patient's or client's record as directed. For example, if a therapist is measuring range of motion or girth, another person may record that information as appropriate in the chart. It is recommended that each facility include in its documentation policy what information can be documented and by whom and what kind of authentication is required.
A note about abbreviations in documentation: Abbreviations can be a quick and efficient way of documenting information. However, use of unknown or confusing abbreviations can be the source of communication breakdown.
APTA does not endorse any particular set of abbreviations. The association recommends that PTs and PTAs use abbreviations sparingly. Facilities/agencies should clearly define what abbreviations are allowed in clinical documentation.
Improper and excessive use of abbreviations also can cause frequent denials in payment. A clinic may wish to develop a key of frequently used abbreviations on most documentation forms or request that therapists completely spell any word the first time it is written with the shortened form in parentheses; for example, "American Physical Therapy Association (APTA)." In addition, send your approved abbreviation list with any requested documentation that will be reviewed by payers. This will assist the payers in their review process.
The Joint Commission has a list of "do not use" abbreviations.