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How to Make Notes Professional Physical Therapy

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In today’s video, Tim Fraticelli, a physical therapist and founder of ptprogress.com, discusses how to write a physical therapy progress note. He breaks down the key components of a progress note and shares tips for more efficient documentation. Tim includes a full progress note template available in the video description or at ptprogress.com/templates to help clinicians save time and improve note quality. He emphasizes the importance of progress notes in therapy and invites viewers to subscribe for weekly helpful videos. The video is sponsored by Medbridge, which offers a discount with a promo code.

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Below are some common questions from our customers that may provide you with the answer you're looking for. If you can't find an answer to your question, please don't hesitate to reach out to us.

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What is the assessment part of a PT note?

The physical therapy assessment portion of a therapy note is the why behind the treatment you provided during your patients visit. A great therapy assessment accomplishes two things: It highlights the necessity for skilled therapy. It identifies areas to address in future treatments.

What goes in a PT SOAP note?

SOAP is an acronym thats short for Subjective, Objective, Assessment, and Plan. A physical therapy SOAP note is entered into a patients medical record to chronicle each episode of care, share information with other healthcare providers, and inform the clinical reasoning process.

How do you write a good physical therapy note?

Writing a SOAP Note Self-report of the patient. Details of the specific intervention provided. Equipment used. Changes in patient status. Complications or adverse reactions. Factors that change the intervention. Progression towards stated goals. Communication with other providers of care, the patient and their family.

What is subjective in a therapy note?

Subjective This section contains information relevant to what the client reveals in the session. This may be the clients chief complaint, presenting problem and any relevant information. This information may include direct quotes from the client. This section also includes things discussed during session.

What is an example of a subjective physical therapy note?

Subjective Examples: The patient reports difficulty sleeping on his side due to shoulder pain. He presents today with 4/10 pain along the left biceps. docHubing behind his back to tuck in his shirt has become easier over the past week. Today the patient reports increased swelling in her knee.

What is the difference between subjective and Objective in therapy notes?

Symptoms are what the person tells you is going on physically, psychologically, and emotionally. They are the clients subjective opinion and should be included in the S part of your notes. Signs are objective information related to the symptoms the client expressed and are included in the O section of your notes.

What is subjective in SOAP note PT?

Subjective. This component is in a detailed, narrative format and describes the patients self-report of their current status in terms of their current condition/complaint, function, activity level, disability, symptoms, social history, family history, employment status, and environmental history.

What is a subjective note?

The SUBJECTIVE section of the note includes information that is told to you. This includes information the patient reports to you verbally (for example, their SYMPTOMS) or information their family shares with you.

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Make Notes Professional Physical Therapy