Physical Therapy Documentation Best Practices and Tips

META-5-1024x538 Physical Therapy Documentation Best Practices and Tips

Physical therapy documentation is vital in assessing the patient’s medical condition throughout the treatment. Also, accurate documentation helps in getting higher reimbursement amounts from insurance companies. If the documentation is improper, services and billing are not correctly mentioned. It results in claim rejections or incomplete reimbursement amounts.

Physical therapy documentation simply records relevant information on patient care, diagnosis, and treatment progress. Physical therapy practice must perform therapies on patients and document details to collect claim payments.

Best practices help the physical therapist document each minute detail related to patient treatment and avoid confusion while assessing the patient’s medical record.

This blog will show the best practices for physical therapy documentation to improve documentation quality and accuracy.

What is Physical Therapy Documentation?

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Physical therapy documentation documenting all the patient’s treatment/care details. It includes current diagnoses, treatment plans, medication, goals, and service billing. It helps physical therapists track the patient’s health progress and current condition. Also, to adjust treatment plans.

The insurance company wants correct billing documentation for physical therapy services to reimburse the claim amount. If the documentation is incorrect, the claim will be refused, and the claim amount will be forfeited.

Physical therapists can access patient’s medical records, including past diagnoses and medication history, through physical therapy EMR software. If healthcare providers incorrectly update the patient’s medical record. It will create difficulties in the assessment of diseases for physical therapists.

Complete and accurate documentation allows practices to handle patients successfully and make more income.

Why is Physical Therapy Documentation Important?

Physical therapy documentation is essential for accurate billing because Correct diagnosis and procedural codes help get higher claim reimbursement amounts from insurance companies. The codes are decided based on documentation that mentions the physical therapy services provided. Improper or incomplete documentation will create difficulties in billing for submitting claims, resulting in rejections of claims.

Proper documentation allows practices to educate patients about their health condition, treatment plan, and health progress.

It is also essential for communication as the patient’s medical record can be shared with different healthcare providers. Based on physical therapy documentation, Providers can understand a patient’s medical history, treatment plan, and medication history. It results in improved patient care.

Physical therapy documentation shows the detailed treatment history of the patient. It acts as evidence in case any legal action will be taken against the physical therapy practice.

Physical therapists can refer any patient to a specialist and easily share the patient’s medical record, such as treatment history, diagnoses, and medication history. It increases the continuity of care and care coordination.

7 Physical Therapy Documentation Best Practices And Tips

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1. Trim the Excess: Eliminate Irrelevant Documentation

Quality documentation should be preferred over quantity of information. Irrelevant information wastes time, lowers productivity and causes ignorance about necessary details. Hence, to avoid this, specific information should only be documented.

Clear and concise documentation helps providers and practices to understand patient health conditions clearly and quickly. For this, It is essential to document only required details related to patient care and exclude irrelevant information. Proper documentation guides patients about their health condition and explains the services practice charging for reimbursement to insurance companies. Physical therapy only needs intake details, diagnosis codes, and treatment plans.

Using standardized or customizable templates helps gather essential information only, Which reduces irrelevant details. Unnecessary repetition of the same information should be avoided.

Quality documentation should be preferred over quantity of information. Irrelevant information wastes time, lowers productivity and causes ignorance about necessary details. Hence, to avoid this, specific information should only be documented.

Standardized accurate documentation comes under the physical therapy best practices.

2. Document all of your Therapeutic Activities

Documentation of therapeutic activities such as Range of motion exercises, Strengthening exercises, Flexibility exercises, Soft tissue mobilizations, and Massage plays an important role in maintaining complete patient records. It should include all the activities performed in detail during the treatment. Specific and standard terminologies should be used while documenting therapeutic activities. The patient’s record of therapeutic activities should also be documented such as changes in symptoms, pain levels, etc.

The reason for changing or modification in the treatment plan should also be documented. The physical therapist should also document activities that helped the patient to complete the treatment goal.

3. Use Shortcuts to Save Time

Documentation of physical therapy services takes more time which reduces the productivity of a practice. Using clear and accurate shortcuts is important for healthcare providers to understand terminologies. Implementation of Physical therapy EMR software suggests globally used shortcuts and helps reduce documentation time. Some of the shortcuts used in physical therapy such as

  • Hx: History
  • PMH: Past Medical History
  • PSH : Past Surgical History
  • FH : Family History
  • O/E or OE: On Examination
  • Sx: Symptoms
  • Dx: Diagnosis
  • Tx: Treatment
  • Pt: Patient
  • C/O: Complains Of
  • ROM: Range of Motion
  • AROM: Active Range of Motion
  • PROM: Passive Range of Motion
  • MMT: Manual Muscle Testing
  • ADLs: Activities of Daily Living
  • HEP: Home Exercise Program
  • PE: Physical Exam
  • ROS: Review of System

4. Validating the Provided Treatment

To get higher reimbursement, practices need to justify the treatments provided. If the treatment is not explained clearly, the insurance company will deny the claim. It results in a loss of reimbursement amount for the treatment provided.

The services rendered should justify the efforts taken on the patient’s health. This includes mentioning data from tools that measure pain, assess function and test strength. Which reflects as evidence of the patient’s health progress. It should include treatment goals and how each treatment session helped in the progress of the patient’s health.

The customization of treatment as per the patient’s health condition should also be documented. Communication with the patient and their family members about the treatment plan should also be documented.

5. Seek Precise Patient-Centered Service Documentation

It specifies the documentation that should be done keeping the patient at the center. Physical therapists should document the patient’s medical information such as assessments, patient disease, and treatment plans in clear language. So that patients should easily understand how the physical therapist’s treatment and intervention will improve their health.

The consent of the patient for all treatments and procedures should be documented. The documentation should educate the patient about their treatment plan, health condition, and progress of health.

The documentation should follow HIPAA regulations which protect the patient’s sensitive health information. Precise patient-centered documentation improves patient care and treatment management for physical therapy practices.

6. Tailor your setup

Customization of practice setup for efficient documentation improves efficiency and patient care. Creating a comfortable workspace can make documentation easier and prevent back pain. This can be achieved by setting up the computer and keyboard at the right height.

Implementation of EMR/EHR software helps in collecting patient details in less time and avoids manual work. This improves the quality of documentation.

The use of customized templates for patient registration, appointment scheduling, and encounter notes reduces manual work and saves time. The software in which documentation takes place should be HIPAA compliant to protect patient-sensitive health information.

EMR/EHR software also helps in pulling the complete current and past medical records of patients. It helps in documenting each detail related to the patient’s medical treatment. The use of standard terminologies helps in the documentation of medical treatments.

7. Use the buddy system

Buddy system terms used in physical therapy documentation. It specifies that two or more healthcare providers work together for effective physical therapy documentation. In this, they review and cross-check the documentation to ensure accuracy and ease of understanding.

In this both the healthcare providers review each other’s documentation and give suggestions for corrections to be made. Discussion with a buddy about the patient’s clinical treatment, and diagnoses helps in creating more patient-centered documentation.

Before finalization of the patient’s encounter notes the buddy of the physical therapist checks accuracy and standards used in documentation.


This blog focuses on the importance and benefits of documentation for physical therapy practices. The best quality documentation can be achieved by use of best practices. Such as documenting all therapeutic activities, avoiding irrelevant information, and creating patient-centered documentation.

Using a buddy system and justifying the treatments provided improves the efficiency of practice and patient care. Better documentation of physical therapies helps in getting more reimbursement amounts from payers.

It also helps in communication with other healthcare providers. The shared documentation of patients’ medical records helps providers understand the patient’s health condition. Physical therapy EMR software helps practices manage more patients and in the documentation for services provided.

Implementation of physical therapy best practices and tips improves the quality of documentation. It reduces the time spent on documentation and increases the accuracy.

Frequently Asked Questions

1. What is physical therapy documentation?

Documenting patient health treatment details, such as patient diagnoses, medication history, and treatment plans called physical therapy documentation. It also includes services provided for improvement in patient health, goals, and patient progress. Physical therapy’s best practices for documentation help get reimbursement claims from the payer. It also educates patients about their health condition and treatment plan.

2. How can Physical therapists protect patient confidentiality in their documentation?

Physical therapists can protect patient health information by implementing HIPAA regulations in the software. By implementing access control, only authorized persons can access patient medical information.

The patient record can also be secured with the use of encryption while sharing with other healthcare providers.

3. How can electronic health records (EHRs) enhance physical therapy documentation?

Electronic health records improve physical therapy documentation as they provide access to a patient’s complete medical record. It includes diseases, medication history, and treatment plans. Also, EHR provides customizable templates that help physical therapists quickly record patient assessments, treatment plans, and progress notes.

EHRs can be integrated with billing software. It suggests accurate billing codes for services provided and helps in accurate documentation.

EHRs are HIPAA compliant, which protects patient health information securely. Physical therapy EMR software Development helps practices solve concerns related to documentation.

Ganesh Varahade

Founder & CEO of Thinkitive Technologies.

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