The American Physical Therapy Association has set forth guidelines for physical therapy professionals. These guidelines ensure proper patient care and communication with the doctors who have prescribed physical therapy for their patients. Guidelines provide consistency across the field of physical therapy. These guidelines are required by the American Physical Therapy Association and are also used for billing purposes.
Patient History and Initial Evaluation
Documentation in a physical therapy report must include the patient's medical history and an initial evaluation made by the physical therapist. The patient history includes medications, prior injuries, prior surgeries and medical conditions. The physical therapist should also perform an initial evaluation and document the evaluation. The evaluation should include tests, system reviews and measurements.
Diagnosis and Prognosis
A diagnosis should be indicated in a physical therapy report. The diagnosis should include the reason for attending physical therapy, level of physical impairment, activity limitations and restrictions as determined by a physical therapist. A report should also include a prognosis. The prognosis in an indication of the type of exercises and physical therapy modalities needed to reach a favorable outcome, along with the duration of time needed to reach this level.
Care Plan
A physical therapist should create and document a care plan for each patient. A care plan is a general outline of the issues that will be addressed in physical therapy. This can include goals, interventions, time frame, number of therapy sessions and plans following discharge from physical therapy.
Visits and Re-examination
A physical therapist should document all physical therapy visits, types of exercises performed during therapy and the progression of the patient. A physical therapist should re-examine the patient during each visit. A re-evaluation of a patient can help a physical therapist and doctors make changes to the course of treatment, if needed.
Discharge Summary
All physical therapy documentations should include a discharge summary. A discharge summary includes the events that occurred during physical therapy and the progress of the patient. A discharge summary can also include post-discharge plans -- such as home physical therapy and exercise programs.
References
- American Physical Therapy Association; Guidelines Physical Therapy Documentation of Patient/Client Management
- "Effective Documentation for Physical Therapy Professionals"; Eric Shamus and Debra Stern; 2003
