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Many PTs find it difficult to document effectively while providing patient and client care. As a result, PTs often view documentation as onerous, irrelevant, and unwarranted. However, the processes of coordination, communication, and documentation are critical to ensure that individuals receive appropriate, comprehensive, efficient, person-centered, and high-quality health care services throughout the episode of care. Coordination involves all parties working together with the individual. Communication is the exchange of information. Documentation is any entry into the individual's health record—such as a consultation report, initial examination report, progress note, flow sheet, checklist, reexamination report, or summation of care—that identifies the care or services provided and the individual's response to them. Documentation should follow the APTA Board of Directors guidance document Guidelines: Physical Therapy Documentation.

 

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