Physical Therapy Documentation Stages

Physical Therapy Documentation Stages

Nitin Chhoda explains the different stages of physical therapy documentation.  Pointing out important guidelines to follow to ensure a smooth documentation process and avoid redundancy.

physical therapy documentation stagesThe speed of physical therapy documentation with which a patient recovers with physical therapy is determined by many factors.

But one thing that physical therapists have control over is the level of care a patient gets, from one appointment to the next.

If each step isn’t documented well, the patient may end up repeating things or wasting time going over their own history with the physical therapist rather than working on getting better.

Physical therapy documentation is extremely important to the process of helping patients to recover and become stronger.

Initial Evaluations

The first stage in physical therapy documentation is the initial interview and examination of the patient. This is an incredibly important process, as it will determine the rest of the treatment plan for the patient.

Of course, the basic patient information will also be gathered and input, assuming electronic health records have not been transferred by a referring physician, as well as details about the injury or pain that the patient experienced.

Every detail is not only important, but may be vital for compliance. And the entire course of the physical therapy documentation and treatment will be determined from the current state of the patient’s health. Goals must also be established so that the progress of the patient can be measured against those goals.

SOAP and Other Details

While taking care of the patient should be the primary concern of the physical therapist, there should also be attention paid to the way the patient’s insurance company will be billed. Some insurance companies have very specific requirements for continuation of treatment and reevaluations.

Rather than risk a rejected or denied claim due to incorrect or insufficient physical therapy documentation, ensure that all physical therapists follow procedural guidelines for documenting the intake of each new patient.

SOAP, or subjective, objective, assessment, and plan, is the standard system of evaluating a new patient. This standard is important for a few reasons.

First of all, it ensures that there is a standard for all physical therapists. Second, when using SOAP, the most important parts of each initial evaluation will be included in the physical therapy documentation.

Subsequent Visits and Treatmentphysical therapy documentation phase

The actual physical therapy documentation and treatment plan should be on a realistic schedule with various stages and goals worked into the physical therapy documentation plan.

Patients are often helped greatly if they can imagine what their life will be like when they feel better. And to have some intermediary goals will keep them thinking ahead and about improvement.

And of course, each session should be well documented with details about the patient’s recovery and activities. The next session will go more smoothly if a detailed physical therapy documentation account of the current session is in the patient record.

This will help the patient to recover as quickly as possible and to make the most of their time with their physical therapist.

Conclusion of Treatment

Just because a patient is done with their treatment, doesn’t mean it’s okay to forget about physical therapy documentation protocol. The patient’s last visit does not signal the last responsibility of the physical therapist or the practice.

Discharge notes will identify what the billing staff can bill for and the information may be useful for future patients or for the management staff, so assessments can be accomplished with real data.

Physical Therapy Documentation System Benefits

Physical Therapy Documentation System Benefits

Changing your physical therapy documentation to an automated setting is now possible. Nitin Chhoda discusses the advantages of using an electronic medical records (EMR) system that will automate your documentation process.

He specifies the benefits of using a web-based setting, and provides examples of how an automated system can provide your practice with instant access to patient records.

physical therapy documentationPhysical therapy documentation has different systems. Maintaining paper records system has become something of a legacy in most industries.

Electronic databases have taken over the world, hosting large quantities of data that previously would have been unthinkable.

But despite this worldwide shift, the medical profession continues to operate mostly on paper.

Only 10% of US medical practices have a fully-integrated physical therapy documentation solution, while a slightly larger but still unreasonably small 20% have some form of electronic medical records.

That is terrible. Especially considering that web-based physical therapy documentation systems are now so powerful. There are physical therapy documentation tips provided in other part of this website.

As of the moment, here are some of the advantages that a web-based solution have over other options for physical therapy documentation.


“Web-Based” Means “Available Everywhere”.

By basing your physical therapy EMR system on a web-based tool, you are ensuring that you can reach the files no matter where you are. Websites are reachable from anywhere that there is an internet connection, and this means that you could access and read over your records at home, when making house calls, or when someone needs an over-the-phone consultation.

Physical therapy documentation for physical therapy services that are based on the web make sure that your files are reachable when you want them, no matter where you want them. And that is something you just can’t do with paper records.

Send with Ease.

Just like you can access the files from anywhere, you can give other physical therapists access to your records with little difficulty.

physical therapy documentation system

This is where web-based solutions truly begin to beat even other physical therapy documentation systems that are based on local servers.

When your data is stuck on a server at your office, you aren’t going to be able to share them as easily as you can with a web-based server.

Access from Any Device.

Want to use your records on an iPad? No problem! A web-based solution is easily accessible on an iPad. Other local types of physical therapy documentation software usually aren’t.

Being accessible from an iPad from anywhere means that you can take a small, lightweight tablet with you wherever you go, documenting the case as you work. It makes managing each patient record incredibly simple.

And of course, if you decide that your office wants to use Mac instead of Windows computers, well, that’s no problem.

Unlike solutions that use dedicated clients to access the information, a web-based physical therapy documentation solution is capable of being viewed on any device with an internet connection and a browser.

A Single Web Server Means Less Maintenance.

Here’s something you probably didn’t think about: managing software upgrades with traditional physical therapy documentation software means upgrading every computer that runs the software and troubleshooting problems that occur on each. But with a web-first approach, a cloud-based EMR tool only has to be updated once.

All changes will instantly be pushed out to all computers that access the tool. Going web-based for your physical therapy documentation solution just makes sense. It simplifies the difficulty of server management even as it makes your data simpler to access.