Documentation Review Sample Checklist
REVIEW FOR MEDICAL RECORDS DOCUMENTATION
Physical Therapy
Note: This is meant to be a sample documentation review checklist only. Please check payer, state law,
and specific accreditation organization (i.e., Joint Commission, CARF, etc) requirements for
compliance.
Therapist reviewed: Privileged and Confidential
PT Initial Visit Elements for Documentation Date: N/A Yes No
Examination:
1. Date/time
2. Legibility
3. Referral mechanism by which physical therapy services are initiated
4. History – medical history, social history, current condition(s)/chief complaint(s), onset, previous
functional status and activity level, medications, allergies
5. Patient/client’s rating of health status, current complaints
6. Systems Review – Cardiovascular/pulmonary, Integumentary, Musculoskeletal, Neuromuscular,
communication ability, affect, cognition, language, and learning style
7. Tests and Measures – Identifies the specific tests and measures and documents associated findings
or outcomes, includes standardized tests and measures, e.g., OPTIMAL, Oswestry, etc.
Evaluation:
1. Synthesis of the data and findings gathered from the examination: A problem list, a statement of
assessment of key factors (e.g., cognitive factors, co- morbidities, social support, additional services)
influencing the patient/client status.
Diagnosis:
1. Documentation of a diagnosis - include impairment and functional limitations which may be
practice patterns according to the Guide to Physical Therapists Practice, ICD9-CM, or other
descriptions.
Prognosis:
1. Documentation of the predicted functional outcome and duration to achieve the desired functional
outcome
Plan of Care:
1. Goals stated in measurable terms that indicate the predicted level of improvement in function
2. Statement of interventions to be used; whether a PTA will provide some interventions
3. Proposed duration and frequency of service required to reach the goals (number of visits per
week, number of weeks, etc)
4. Anticipated discharge plans
Authentication:
1. Signature, title, and license number (if required by state law)
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PT Daily Visit Note Elements for Documentation Date: N/A Yes No
1. Date
2. Cancellations and no-shows
3. Patient/client self-report (as appropriate) and subjective response to previous treatment
4. Identification of specific interventions provided, including frequency, intensity, and duration as
appropriate
5. Changes in patient/client impairment, functional limitation, and disability status as they relate to the
plan of care.
6. Response to interventions, including adverse reactions, if any.
7. Factors that modify frequency or intensity of intervention and progression toward anticipated goals,
including patient/client adherence to patient/client-related instructions.
8. Communication/consultation with providers/patient/client/family/ significant other.
9. Documentation to plan for ongoing provision of services for the next visit(s), which is suggested to
include, but not be limited to:
The interventions with objectives
Progression parameters
Precautions, if indicated
10. Continuation of or modifications in plan of care
11. Signature, title, and license number (if required by state law)
PT Progress Report Elements for Documentation ** Date: N/A Yes No
1. Labeled as a Progress Report/Note or Summary of Progress
2. Date
3. Cancellations and no-shows
4. Treatment information regarding the current status of the patient/client
5. Update of the baseline information provided at the initial evaluation and any needed reevaluation(s)
6. Documentation of the extent of progress (or lack thereof) between the patient/client's current
functional abilities/limitations and that of the previous progress report or at the initial evaluation
7. Factors that modify frequency or intensity of intervention and progression toward anticipated goals,
including patient/client adherence to patient/client-related instructions.
8. Communication/consultation with providers/patient/client/family/ significant other
9. Documentation of any modifications in the plan of care (i.e., goals, interventions, prognosis)
10. Signature, title, and license number (if required by state law)
** The physical therapist may be required by state law or by a payer, such as Medicare, to write a progress report. The daily
note is not sufficient for this purpose unless it includes the elements listed above.
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PT Re-examination Elements for Documentation Date: N/A Yes No
1. Date
2. Documentation of selected components of examination to update patients/client's impairment,
function, and/or disability status.
3. Interpretation of findings and, when indicated, revision of goals.
4. Changes from previous objective findings
5. Interpretation of results
6. When indicated, modification of plan of care, as directly correlated with goals as documented.
7. Signature, title, and license number (if required by state law)
PT Discharge/Discontinuation/Final Visit Elements for Documentation N/A Yes No
Date:
Note: discharge summary must be written by the PT and may be combined with the final visit note if seen by the PT on final
visit
1. Date
2. Criteria for termination of services
3. Current physical/functional status.
4. Degree of goals and outcomes achieved and reasons for goals and outcomes not being achieved.
5. Discharge/discontinuation plan that includes written and verbal communication related to the
patient/client's continuing care.
6. Signature, title, and license number (if required by state law)
PTA Visit Note Elements for Documentation Date: N/A Yes No
1. Date
2. Cancellations and no-shows
3. Patient/client self-report (as appropriate) and subjective response to previous treatment
4. Identification of specific interventions provided, including frequency, intensity, and duration as
appropriate
5. Changes in patient/client impairment, functional limitation, and disability status as they relate to the
interventions provided.
6. Subjective response to interventions, including adverse reactions, if any
7. Continuation of intervention(s) as established by the PT or change of intervention(s) as authorized
by PT
8. Signature, title, and license number (if required by state law)
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