Physical therapy, just like any treatment plan, is part of a collaborative effort to return a patient to the best possible health. The need for interdisciplinary communication is one reason why physical therapy documentation is so critical. The initial order comes from a supervising physician. This doctor, along with a team of other healthcare professionals, monitors the patient’s progress and makes changes based on what they see in the PT record. Understanding the four distinct areas of documentation will clarify the process.
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Initial Interview of physical therapy
The first physical therapy session involves an assessment of a patient’s mobility limitations, medical history and lifestyle. This is a time for the therapist and client to get to know each other. The PT professional will discuss goals and milestones that gauge a patient’s progress. The examination may include some movement exercises that provide assessment data to help the physical therapists develop a treatment plan.
This initial interview will conclude with the PT staff beginning the documentation that will become part of the patient’s medical history. It will include a referral order from the doctor, notes on the exam and details of the interview.
Session Records
Each time there is a session, the therapist will take detailed notes. This includes documenting what exercises were done, suggestions for plan changes and milestones met. The staff notes missed appointments and future schedules as well. The professionals at the PT office will grade mobility and document level of pain. They may send reports to the primary care physician regarding new complaints or request a change in a therapy order.
Evaluations
Part of the therapist’s job is to evaluate the progression of the treatment. This includes taking notes on ways the patient’s situation has advanced over the weeks, and how the care plan is affecting overall health. The evaluation includes the patient’s view on his or her progress.
Different PT centers have different evaluation methodology. In most cases, the documentation includes the patient’s feelings about recovery plus a practical look at mobility prognosis and recovery rates. The physical therapy documentation at this stage may be part of a care team meeting to discuss treatment protocols for this patient or reviewed by each member separately for suggestions or additional orders.
Discharge Papers of physical therapy
For most patients, the day comes when physical therapy ends. The PT staff will conclude their work by creating a discharge report. This process is twofold. In may include home care instructions for the patient that discuss ways to continue exercising and maintain health. There may be a list of dos and don’ts to avoid further injury.
The discharge report will become part of the patient’s chart, and summarize the disease or injury and care plan, document the physical therapy course taken and gauge the level of success.
Discontinuation Report
A discontinuation report is a record that details why physical therapy stopped prior to completion. Like the discharge document, it discusses the patient’s health but includes reasons why the therapist did not complete the treatment cycle. The health situation may have changed, for example, or a new therapist may have taken over. In some cases, the patient chooses to terminate the care.
Physical therapy is a medical care program that improves mobility and overall health. The physical therapy documentation that goes along with it is a vital part of a patient’s medical history.
About the Author: Gloria Sanchez, a secretary for a physical therapist who likes to write blogs on the weekends when she isn’t spending time with her family.
