Written by a Physical therapist or PT assistan. Each therapy session, interventions provided, response to interventions, any changes, any consultation with other providers

Notes of any untoward incident or accident related to one’s function as therapist

Written by PT, provides an update of the patient status over a number of visits or certain periods.

Allows or endorses a patient’s treatment to be done by another therapist. Change of therapist

Written by PT, For discharge/discontinuation of care, Documents current physical/functional status of patient, Includes degree to which goals were achieved and reasons if not achieved, Provides a discharger discontinuation plan related to the patient’s continuing care.

Written by Physical Therapist and Required at the onset of episode of PT care.

What purpose of Note Writing shows If services is of quality and Skilled treatment

What purpose of Note Writing shows ensures coordination and continuity of patient care and Organization of treatment?

What purpose of Note Writing shows the justification of the effectiveness or the proof of effectiveness of the intervention?

What purpose of Note Writing shows the document of the patient's problems so

that an appropriate plan of care can be established

What purpose of Note Writing specifies the intervention and shows that the patient has been seen and treated, in response to intervention?

This is the simplest form of documentation, recounts what happened in a therapist-patient encounter, therapists can and should develop their own outline of information to cover. These outlines can be more or less detailed, specific information listed in each heading is left to the writer's discretion.

This is the highly structured documentation. Developed by Dr. Lawrence Weed as part of the problem-oriented medical record.

This is relatively new format and focuses on documenting the ability to perform meaningful functional activities rather than isolated musculoskeletal, neuromuscular, cardiopulmonary, or integumentary impairments. Establishes the rationale for therapy by indicating the links between impairments and participation restrictions because in the patient Emphasizes readability by healthcare personnel or by persons not familiar with PT jargon.

PTs uses this type of report format to document their findings from an evaluation or convey what has occurred in the visit

This is an Integral part of PT documentation. This outcome measures have been determined to be reliable and ideally validated in specific patient populations. Very useful to quantify improvements in patients' performance.

This provides visualization of patients' progress in therapy. Improves readability and readily focuses a reader on critical issues. Also, it documents multiple findings of similar impairment or functional skills and documents changes over multiple sessions.

This is a strategy in documenting wherein there is a limited amount of wording and use of abbreviations and medical terminology

This is a strategy in documenting wherein the standard forms that therapists can use to fill in the blanks. Ensures pertinent items are covered and provide a consistent format for assessing different patients. No line should be left blank.

This is a strategy in documenting wherein the notes should include only those observations and interpretations that are essential for documenting the patient’s current medical condition.

This is a key legal aspect in documentation that all notes must be dated when the note was written. All notes should be written on the dates that an evaluation or intervention is performed. If a note is not written on the date, then both the date of the evaluation/intervention and the date the report was written should be indicated.

This is a key legal aspect in documentation that PT documents must be authenticated by a PT or PT assistant (when appropriate). All notes must be signed, followed by the writer’s professional abbreviation and dated.

This is a key legal aspect in authentication that shows PT/PTA, Highest earned PT-related degree, Other earned academic degree, Specialist certification credentials in alphabetical order, Other external credentials, Other certification or professional honor.

This is a key legal aspect in authentication that shows PTA can typically sign treatment notes only and PTs may be required to co-sign each note written by PTA.

This is a key legal aspect in authentication that shows PT/PTA, Highest earned PT-related degree, Other earned academic degree, Specialist certification credentials in alphabetical order, Other external credentials, Other certification or professional honor.

This is a key legal aspect in authentication that the PT should place a single line through the error and write initials near the crossed out word. Include date and time of correction.

This is a key legal aspect in authentication that this should be avoided and single line should be drawn through any open spaces.

This is a key legal aspect in authentication that PT should only use accepted and

authorized abbreviations.

This should be avoided in note writing.

TRUE or FALSE: The format on orders indicate time, date, and order followed by the doctor’s name, the therapist, and latter’s designation.

Information obtained from the patient or relatives or care taker

Has the question "Why the patient sought PT consultation?".

Events that led to the patient’s c/c. Arranged chronologically

All conditions/injuries of the patient, onset preferred

Diagnostic studies or procedures performed including date, place taken, and results or findings

Medications taken in the past including the dosage, frequency, and indication

Medications currently being taken including the dosage, frequency, and indication

Includes the medical conditions existing in the family

Includes the patient’s lifestyle, home/work environment, living situation, diet and nutrition, vices, work set-up (hours, demands, etc), etc.

What does the patient want to achieve after the PT

Contains results of measurements and tests. Includes therapist’s objective observations.

BP, Temperature, Pulse rate,

Respiratory rate, O2 saturation

Includes the patient’s manner of arrival, level of assistance needed, patient;s physique/nutritional status, mental status, level of consciousness accessories & attachments, features & deformities present

Includes muscle tone, temperature of affected are, muscle spasm, tenderness, edema

Includes a table of measurement of available joint motions. Includes a narrative/summary of findings and significance of the findings

Includes a table of muscle strength grade. Includes a narrative/summary of findings and significance of the findings

Includes: i. limb girth measurement for swelling ii. muscle bulk measurements for muscle atrophy iii. Head circumference in pediatric patients iv. Leg length measurements for leg length discrepancy. Includes a narrative/summary of findings and significance of the findings

Includes: i. sensory assessment ii. Deep tendon reflexes iii. Balance and coordination assessment iv. Memory and cognitive assessment v. Etc ● Includes a narrative/summary of findings and significance of the findings

Includes standing and sitting posture seen in anterior, posterior, and lateral views ● Includes a narrative/summary of findings and significance of the findings

Includes: i. the patient’s manner of ambulation ii. gait deviations noted during the stance and swing phases iii. Other characteristics of gait such as step length, stride length, cadence, etc. iv. Assistive device used ● Includes a narrative/summary of findings and significance of the findings

Any provocation or clearing test. Includes a narrative/summary of findings and the significance of the findings

Present function of patient in terms of performing ADLs, IADLs, work-related, or sports-related functions. Includes a narrative/summary of findings and significance of the findings

Includes the standardized outcome measure included in examination. Includes a narrative/summary of findings and significance of the findings

Contains the therapist’s interpretation of the findings/results from examination. Provides a summary of the examination an PT’s clinical judgment about the case

Meaningful narrative and interpretation of the findings of the examination. Correlation with the patient’s medical diagnosis

Includes positive and negative prognosticating factors that may affect the patient’s outcomes

Includes a refined problem list in which examination findings are classified into impairments, activity limitations and participation restrictions and prioritized problem list that lists down the problems based on a priority (functional, addressed by PT, etc)

Activities/outcomes that the patient will achieved in a specific period ● Goals must be SMART (Specific, measurable, attainable, realistic, time-bound)

Includes the PT techniques and procedures that will be used to accomplish the goals

Includes modalities, exercises for the patient including their complete parameters/dosimetry and rationale

Patient/family/caregiver education provided

Exercises that patient will do at home including their complete parameters/dosimetry and rationale. Written in plain language and may include pictures

Includes the need of referral to other

discipline and the reason for the referral