One of the reasons that PT documentation is such a crucial part of the treatment of the patient is that it provides a consistent source of information for every stage of physical therapy treatment. The process of treating a patient with physical therapy is lengthy and there are many phases the patient will pass through before he or she is healthy and ready to complete their treatment. Each stage of the process of helping a patient recover their health must be carefully and consistently documented so that the next time that patient shows up for treatment, the process can begin without interruption, repetition or error.

Of the several stages of PT documentation, the initial interview and examination may be the most important. This phase is often referred to as the initial evaluation and it is during this time with a new patient that basic information is gathered including identification data, cause and nature of the injury or problem, and reimbursement information, such as insurance contact records that will be needed in every other stage of the treatment plan.

It is during the initial evaluation that a notation standardization system called SOAP will be introduced. This system, which stands for “subjective, objective, assessment and plan,” is an important industry standard that will help to assure consistency in the documentation of every PT patient from the minute they come to your practice for treatment all the way through to completion of their treatment plan.

There are specific areas of documentation that will be set up during the initial assessment and updated each time a patient is treated. Along with basic contact information, pertinent details about the patient’s medical situation that come from the referring doctor must be added to the PT documentation as well. During the course of the actual PT exam and evaluation, details of the condition of the patient must be documented carefully. This becomes the benchmark starting place against which progress reports will be measured. From this base of evaluation data, goals for the patient must be established and documented during the initial evaluation so that clear-cut progress toward those goals can be shown and further treatment is justified.

From that solid base of PT documentation, each session with the patient is documented as well, using the standardized SOAP format. Along with details about what occurred during treatment, progress notes must be placed into the patient file that line up with those initial records and PT goals.

It is essential and required by most insurance programs that from time to time the patient undergoes reexamination and reevaluation. These are important milestones in the treatment of the patient to demonstrate that progress is being made as planned and that the patient is on track toward full recovery. If there have been setbacks or other new incidents or information that will mean prolonging treatment, that must be carefully documented so that coverage can be extended as well. When the reevaluation is done, the PT goals that were detailed during the assessment phase will be reviewed and updated in light of where the patient is on his or her path to wholeness.

Upon conclusion of treatment, discharge notes must also be thorough so that the record is clear about what was achieved. The obvious purpose of doing a complete job with conclusion of service PT documentation is to file claims for the payment that is due with insurance companies or from Medicare. In addition to finishing the “story” of the treatment and lining the progress that was made up with those initial goals that were laid out during assessment, the PT documentation at discharge will detail further at-home treatment or referrals that should be followed so that the patient can continue on his or her path to full and sustainable recovery.

While PT documentation can be a chore, it is essential that these stages of PT documentation be done with care and in full detail so that an accurate trail and diary of treatment is on file. This is certainly important for both financial and legal reasons. It is also a must to have this kind of history for each patient to go to should that patient return to your PT practice for further treatment in the future.

“Prior to WebPT we were not agile or portable. Hardcopy files had the expense of paper, printer ink, manpower hours devoted to the charting process and faxing documents, as well as storage.  If a referral needed an urgent progress note and I was out of town teaching there was no mechanism to even attempt a solution."  Kenji Carp, Owner/Director, Cooperative Performance & Rehabilitation

Pasted from <http://www.webpt.com/resources/practices/stages-pt-documentation>