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the old saying in medicine is if it isnt documented it didnt happen documenting the treatment you provide is a required skill just like the treatments themselves so lets review how to document your intervention properly you need to ensure two things when documenting treatment first that you provide enough information that another clinician could do the exact same treatment and second that youre conveying that skilled care is being provided to your patient when first learning how to document treatment its helpful to remember the acronym to remember the elements that are required in your note youll need to document what treatment was done where that treatment was done and why it was performed you also need to include the parameters for any treatment done the position the patient was treated in and any assistance provided by the physical therapist or physical therapist assistant by providing this information you can ensure that the treatment is repeatable by the next clinic
