Skip to main content

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

Documentation elements for the initial examination and evaluation include the following: history (including review of systems), physical examination, tests and measures, diagnosis, prognosis, management plan, and plan of care.

chart.png

Log in or create a free account to keep reading.


Join APTA to get unlimited access to content.


You Might Also Like...

News

Senate Introduces Companion Legislation To Help Patients Avoid Interruptions

Jul 10, 2025

If enacted, PTs across the country would be allowed to secure substitute care for patients during an absence.

Article

Proposed 2026 Home Health Rule: Implementation of PDGM Leads to 6.4% Cut

Jul 9, 2025

In this review: Medicare and Medicaid Programs: Calendar Year 2026 Home Health Prospective Payment System Rate Update; Requirements for the HH Quality

News

APTA Advocates Against Anthem's Policy for Reporting Timed Units

Jul 9, 2025

APTA urges the insurer to revise the policy and has created a template letter for members to add their voices to the advocacy effort.