As told by a Physical Therapy Assistant, “I spend 60% of my time at job with patients, helping them with their exercises and 40% of my time goes into documentation and writing notes”. In this article, we are discussing the practice methods of clinical physical therapist, through an assessment to evaluation stages. Therapist looking PT documentation, examples, case studies, programs, software or templates for evaluation and comparison different patient’s disorders.
Apart from this, on the internet, we normally see the most talk is in general about Physical Therapy as a whole. But, I haven’t really gone through an article as of yet that lays emphasis on the importance of documentation in this field. The standards of practice framework of physical therapy are very important to understand for each student.
Related Article: Research Topics of Physical Therapy
In this article, I’ll be sharing what goes into the documentation, tips to make the documentation effective and other notes writing.
- Documentation relevant to different types of the physical therapist (Sports, Outpatient)
- Case studies are very important to understand the typical type of physical disorder of a patient, so make sure about it.
- There are lots of practice books for both PTA and PT, which details soap notes, assessment, evaluation and case studies
- Ask PTcareer.info before purchasing any documentation
- Include standards procedures, equipment (Assessment Tools), guideline and other legal issues
Note: Request PTcareer for Free Sample of Physical Therapy Documentation (Comment Us)
Physical Therapy Documentation Phrases
Documentation specifically categorizes into four sections. The term used to represent these sections is SOAP. Different sites give you plenty of assessment or documentation phrases for physical therapy for recording and evaluation of different scenario.
As referred by the name, this section has information about the patient. The therapist collects the information as told by the caregiver and the patient about his/her health condition and the issues he/she faces. This allows having a written history of a patient.
The objective section is for all the treatment-related information. All the performed exercises and suggested techniques are worth mentioning here. For example 10 push-ups, or 20 sit-ups. Hence, this area is for treatment-related facts.
This area is the clinical judgment of the patient done by the therapist using facts and subjective opinions. Therapists make sure to capture this information clinically. For example, if a certain patient is making progress or perhaps still struggling with something.
In this section, you write down how you want your patients to progress. This would perhaps be the very next session or a session later in the future. Hence, the plan section has future detail regarding the patient’s treatment.
Tips on writing PT Documentation more effectively:
Following are some tips on being able to write more effectively:
Think about your audience
For example, on average, a Physical Therapist may consider having the following options about his audience:
In case of absence of the regular therapist, another one might take his/her place and deal with the patient.
Hence, while writing the documentation the therapist makes sure that the fixture therapist fully understands the patient’s history and future needs.
It must be clear from your documentation that you’re providing the patient with correct and the best treatment. According to the patient’s plan, the insurance company representatives may have to come in and go through the documentation.
Court of Law:
In like manner, your documentation should stand out in the court of law. Write information in a way that it can withstand that kind of scrutiny.
In like manner, this is an observed emphasis during the training sessions of Physical Therapy. The potential therapists should strictly observe the following line “If you don’t write it down, it did not happen”.
Additional Precautions that May Help Potential Physical Therapists:
- In the case of departmental accidents, you might get into trouble just because you did not write something down. That’s one reason for thinking about this issue effectively.
- On the contrary, exaggerating the real incidents may also land you in trouble. For example, the documentation must have strict and correct time stamps for patients.
- Be specific about the patient. If there are two patients with similar injuries, it must not be similar copies in both the documentation. You should be able to differentiate between the two just by looking at the documentation.
- There may also be chart reviews that you may need to design for your hospital facility or wherever you work.