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Documentation: Initial Examination and Evaluation

Article
Date: Wednesday, January 31, 2018

The initial physical therapist visit consists of an examination and evaluation. Typically these are completed in 1 visit, but they but may occur over 2 or more.

Documentation elements for the initial examination and evaluation include the following: examination, evaluation, diagnosis, prognosis, intervention, and outcomes.

Patient and client management is an ongoing, iterative process that focuses on the evolving needs of each individual.

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Resource Details

Date: January 31, 2018
Contact:  practice@apta.org
Content Type:  Article

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