Reason for Documentation in physical therapy

1. Communication with Other Health Care Professionals

• Ensures coordination and continuity of patient care.
• Organizes the planning of treatment strategies.

2. Communication with Health Care Administration

• Decides discharge and future placement
• Used as a quality assurance tool.

3. Communication with Third-Party Payers

• Can be used to determine how much should
be billed for a visit.
 Reason for Documentation in physical therapy
4. Guide for Clinical Decision Making
•Apply physical therapy intervention and appropriate plan of care can
be established.
•Provide a structure to allow for evaluation of examination findings in
order to determine a patient's prognosis, diagnosis, and appropriate goals.

5. A Legal Record
• Serves as a business record
•Can be used as legal record of services
provided in case of legal malpractice
 Documentation Formats
• Many possible formats can be used for writing notes.
• In these cases, (Written by Physical Therapist or Physical
• Therapist Assistant) PTs, PTAs, and students should use the
format in general use within the institution.
• This includes electronic medical records, which are used in
most health care centers and many private physical therapy
practices today
What Constitutes “Documentation”?
• Documentation is any form of written communication
related to a patient encounter, such as an initial evaluation,
progress note, session note, or discharge summary.
• Documentation can take many forms, including
1. written reports,
2. standardized assessments,
3. graphs and tables,
4. and photographs and drawings.
1. Written Reports

• Most commonly, PTs use a written report to document their

findings from an evaluation or convey what has occurred in

a patient visit.

• The format of this report can take many forms; the two

most common are a narrative format and a SOAP format.

2. Graphs and Tables
• Graphs can be used as a form
o f documentation to provide a
visualization of a patient's progress in
therapy.
• They can improve readability and readily
focus a reader on the critical issues.
• In this figure, a patient's gait speed is
charted over a period of about 3 weeks.
• This provides an easy visualization
of progress for third-party payers, other
health care professionals, and most
important, the patient.
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Example of table documenting muscle
strength
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A TABLE USED IN A PROGRESS REPORT DEMONSTRATING THE RESULTS OF

THE 6- MINUTE WALK TEST OVER A PERIOD OF 6 WEEKS

Resultsd a 6-Minute Walh

TeV
Distant walked m Feb. S 262
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Mar. S 3S
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3. Photographs, Drawings, and Graphics
• Some aspects of patient care are difficult to describe narratively but may be best
explained visually.
•Photographs (obtained with the patient's written consent) can be used very effectively
for documenting impairments such as posture or wound size or for documenting
functional abilities.
• Alternatively, drawings are typically used to document impairments such as extent of
pain.
• Figure shows the FACES scale, which can be used to document pain in younger clients.
 To effectively integrate evidence-based practice into clinical
documentation, therapists are encouraged to follow specific
strategies recommended by the APTA
(The American Physical Therapy Association):
1. Documenting Valid and Reliable Tests and Measures
2. Use of Standardized Outcome Measures:
• Standardized outcome measures are effective tools for evaluating and
communicating changes in a patient's impairments or functional abilities.
Selecting Evidence-Based Plan of Care and Interventions:
• Therapists should choose and implement a plan of care and interventions based
on available research evidence or clinical guidelines.
• In certain situations, therapists may find it useful to document specific evidence
or provide references.
 Strategies for Abbreviation in
1. Abbreviate Wording
Documentation
• A written medical record has some specific characteristics that differentiate it
from traditional narrative writing.
• One way to save time in medical documentation is by not using full sentence
structures and using abbreviations. Also, eliminating the words his,her,a,the,for,and
an can improve readability of a medical note.
 Strategies for Abbreviation in
2. Abbreviations and Medical Terminology
Documentation
• The first question that must be addressed regarding use of abbreviations is, “Who will be the
reader of this note?” If the answer is “another physical therapist or physical therapist
assistant (and no other person),” therapists can freely use abbreviations and appropriate PT
terminology.

• However, if only a slight possibility exists that the note might be read by another professional
(e.g., physician or nurse) or by a nonprofessional (e.g., administrative staff, claims auditor),
uncommon abbreviations almost certainly will impede understanding.

• home exercise program should be written in lay terminology, avoiding abbreviations and
medical jargon.
• Similarly, any documentation that is sent to third-party payers, and particularly to patients or
their families, should make more limited use of abbreviations.
MD/PT/PTA

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 Strategies for Abbreviation in
3. Avoid Unnecessary and Irrelevant Facts
Documentation
Therapists should generally avoid, or be very careful, when including the
following information in a medical note:
• Detailed social history
• Detailed living situation
• Family history not directly related to current medical condition
•Detailed history of other medical conditions that have been resolved and do not
affect the current Condition

In general, documentation should be kept focused to the information that directly

affects that patient's current health condition.
 Strategies for Abbreviation in
4. Use of Templates
Documentation
• PTs often spend a good part of their working time doing documentation.

• Templates ensure that items are covered and provide a consistent format for assessing

different patients.

• Electronic medical records have facilitated the use of such templates in which

therapists typically use a combination of narrative writing, check boxes.

 Strategies for Abbreviation in
4. Use of Templates
Documentation
• therapist must write one of the following on the line:
5. The results of the test, examination findings, or clinical opinion.
6. N/T (not tested), to indicate that this item was not tested.
• This entry in the note should be followed by a reason the item was not tested
or a plan for testing in the future (e.g., “N/T to time constraints—to be
evaluated ”).
3. N/A (not applicable), to indicate that this test was not applicable for this
particular patient given his or her diagnosis or condition.
The therapist should state why the test or measure is not applicable (e.g.,
“N/A—Pt. is currently on ventilator and unable to get out of bed”).
Key Points in Writing People-First Language
1. Put People First Not Their Disability
Say a womanwitharthri tis, not anarthriticwoman. This puts the
focus on the individual and not on their disability
or medical condition.
2. Emphasize Abilities, Not Limitations
Using the phrase: Walkswithlegbraces, or usesawheelchairfor
olng-distancemobility, is more accurate and
positively focused than confinedtoawheelchairor
wheelchairbound.
3. Avoid Negative Labelling
Saying afflictedwith,crippledwith,victimofor suffersfrom,
devalues individuals with disabilities
Exercise Concise Documentation and Use of Abbreviations
Rewrite these notes as if you were writing them in a medical record. Consider condensing
sentence structure, such as eliminating unnecessary words. Use abbreviations whenever
possible Statement Rewrite Statement
E X A M P L E : Patient can walk a distance of 50 feet in the hospital ANSWER: Pt. walks 50 ft in hospital
corridors corridors
1.Patient underwent a procedure called a coronary artery
bypass graft on 3/17/14.
2.Therapist will coordinate practice of activities of daily
living training with occupational therapist and with nursing
staff.
3.The patient's heart rate changed from 90 to 120 beats per
minute after 3 minutes of walking at a comfortable speed.
4.The patient's obstetric/gynecologic doctor reported that
this patient has been experiencing low back pain throughout
her pregnancy.
5.Patient's daughter reports that patient has had a recent
decrease in her functional abilities and has a history of falls.
6.The patient's breath sounds were decreased bilaterally. The
patient was instructed in performing deep breathing exercises twice
per day.
7.Patient's wife reports that the patient has had a history of
chronic low back pain for the past 15 years.