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Why is PT documentation important?

Keeping clear and complete physical therapy records can help you to: Provide the best care to patients. Keeping a record of your patients initial condition and their journey towards recovery will allow them to receive better care, whether its from you or another healthcare provider.

How do you document physical therapy?

What Are PT Documentation Requirements? Patient details (DOB, name, physician contact information) Medical diagnosis. Past medical and PT treatment history. Medication history. Physical therapy assessment and diagnosis. Physical therapy treatment goals and plan of care. Billing CPT codes.

What is the medical term for PT?

Prothrombin time (PT) is a blood test that measures the time it takes for the liquid portion (plasma) of your blood to clot.

What is an example of a progress note in PT?

Progress Note Example She will come in for her 11th visit at the end of the week. Subjective: The patient reports that her resting shoulder pain has decreased from 4/10 to 12/10 over the first two (2) weeks of treatment. She reports being able to perform her self care and dressing with a maximum pain level of 45/10.

What is a physical therapy note?

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. Physical therapy SOAP notes record the entire process of a therapist interacting with a patient.

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How do you write a PT assessment statement?

Try following this simple outline for an evaluation assessment: Restate the diagnosis. Remark on the patients rehab potential. Identify their key impairments. State why skilled PT is necessary.

Does PT stand for patient?

But sometimes our abbreviations can get a little confusing! As a Physical Therapist, I have to be careful with the pt medical abbreviation because lowercase pt should mean patient, while upper case PT refers to Physical Therapist.

How do I write a PT plan of care?

ing to the APTA, these plans should include at minimum: (1) diagnoses; (2) long-term treatment goals; and (3) type, amount, and duration of therapy services. But, you may also want to include short term goals and discharge plans to make the plan more meaningful to the patient as well as the providers.

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