PHYSIOTHERAPY

DOCUMENTATION
 Though your physical therapy documentation may expand as a
patient continues along an episode of care, general components
of quality physical therapy documentation examples
include: Patient details (DOB, name, physician contact
information) Medical diagnosis. Past medical and PT treatment
history.
The 5 elements in physical therapy

 The physical therapist integrates the five

elements of patient/client management –
examination, evaluation, diagnosis, prognosis,
and intervention – in a manner designed to
optimize outcomes
 Documentation of a visit, often called
a daily note or treatment note, documents
sequential implementation of the physical
therapist plan of care.31 Jan 2018
 However, the American Physical Therapy Association does
provide the following guidance on what information should be
included:
1. Self-report of the patient.
2. Details of the specific intervention provided.
3. Equipment used.
4. Changes in patient status.
5. Complications or adverse reactions.
6. Factors that change the intervention
 Physical therapy, also known as physiotherapy,
may include certain exercises, massages and
treatments based on physical stimuli (e.g. heat,
cold, electrical currents or ultrasound). The aim
of physical therapy is to relieve pain, help you
move better or strengthen weakened muscles.
Why documentation is important for the
physiotherapist ?
 Documentation is also done to provide legal evidence
as to exactly what took place during each therapy
session and also to communicate with other health
professionals. Documentation serves another
important purpose to JUSTIFY to the INSURERS that
proper care was provided and DESERVES to be
reimbursed.
What is physiotherapist note ?

 Physiotherapy is treatment to restore, maintain,

and make the most of a patient's mobility,
function, and well-being. Physiotherapy helps
through physical rehabilitation, injury
prevention, and health and fitness.
Physiotherapists get you involved in your own
recovery.
 Here are some common types of PT:
• Orthopedic PT: Orthopedic PT focuses on
musculoskeletal injuries and conditions, such as
fractures, sprains, and joint replacements.
• Neurological PT: Neurological PT deals with neurological
disorders like stroke, Parkinson's disease, spinal cord
injuries, and multiple sclerosis
EXAMPLE OF QUESTIONS TO PATIENTS :

 WHAT IS YOUR COMPLAIN ?

 WHERE IS THE PAIN ?
 IS IT PAIN HERE ?
 WHAT DO YOU FEEL WHEN I PRESS YOUR………………?
 HAVE YOU EVER GONE TO THE DOCTOR TO CONSULT YOUR PAIN ?
 WHEN IS IT ?
 HAVE YOU TAKEN THE MEDECINE BEFORE ?
 HOW MANY TIMES DO YOU TAKE THE MEDECINE IN A DAY ?
 DO YOU FEEL THERE IS ANY PROGRESS AFTER TAKING THE MEDECINE ?
 WHAT DO YOU FEEL WHEN I PUT ON THIS ULTRASOUND ?
 IS THE HEAT ENOUGH FOR YOU ? ( IS IT TOO HOT FOR YOU ?)
 DO YOU THINK THAT I NEED TO INCREASE THE HEAT ?
 WHAT DO YOU FEEL WHEN I BEND YOUR KNEES ?
 IS IT PAIN WHEN I TOUCH YOUR NECK ?
 HAVE YOU DONE THE EXERCISE AT HOME ?
 DO YOU DO THE EXERCISE THAT I TOLD YOU BEFORE ?
 HOW MANY MINUTES DO YOU TAKE YOUR TIME FOR THE EXERCISES ?
 IS THERE ANY PROGRESS ON YOUR …… AFTER DOING EXERCISES ?