Physical therapy (PT) is a treatment used to strengthen muscles. Doctors may prescribe physical therapy as a part of rehabilitation from an injury or to treat conditions associated with weakened muscles, such as cerebral palsy and Parkinson's disease. PT documentation refers to the records physical therapists keep to track the progress and success of patients. Physical therapy documentation has four steps--the initial examination, recording of sessions, evaluation of progress and the discharge/discontinuation report. Overall PT documentation represents the physical therapy plan a physical therapist has for each individual under her care.
Initial Examination
The initial examination is typically done in one session. In the session, the therapist studies the patient's history and evaluates the patient's physical abilities. Family history, past surgeries, medications and living environment are amongst the elements that should be considered for the history portion of physical therapy documentation. The physical therapist evaluates a patient's physical abilities in order to determine what the person's limitations are and what goals would be reasonable and reachable. Physical abilities the physical therapist will look at may include gait (manner in which the patient walks), nerve integrity, balance and limb mobility. Once the patient is evaluated, the therapist works to create a general physical therapy plan, which dictates goals and how the therapist and patient will proceed in accomplishing these goals.
The names of the physical therapist and patient should both appear in the physical therapy documentation. Also, whoever referred the patient to the therapist, whether the referral came from a doctor, another therapist or another source, should be noted in the initial examination portion of the physical therapy documentation.
Recording of Sessions
Every session the therapist and patient have should be noted in the PT documentation. In this part of the physical therapy documentation the details of the physical therapy plan are recorded. Notes on progress being made and specific exercises being done can be found in this portion of the physical therapy documentation. Any canceled sessions or sessions in which the patient does not show up should also be noted in the PT documentation.
Evaluation of Progress
The therapist and patient should set a time period in which the patient will achieve his goals. For example, say a patient who injured his leg in an automobile accident sets a goal to have full strength back in his leg after a month of physical therapy. After a month passes, the therapist and patient will gather to discuss the recovery rate of the patient. The therapist can use the notes from her physical therapy documentation reports as an assessment tool for evaluation.
For situations in which patients will continually need physical therapy, such as when PT is used to treat disorders like cerebral palsy and Parkinson's disease, the evaluation process of physical therapy documentation will include setting new goals to work toward.
Discharge/Discontinuation Report
When physical therapy is no longer needed, a discharge report will be written to complete the PT documentation process. The discharge report summarizes the sessions of physical therapy and declares any further action the patient will need to take.
If for some reason therapy is discontinued before the objective of the therapy is realized the therapist will fill out a discontinuation report. Reason for the discontinuation will be stated on the discontinuation report.
Tags: therapy documentation, physical therapy, physical therapy, physical therapy documentation, therapist patient, patient will