This Physical Therapy Documentation Cheat Sheet serves as an essential guide for both novice and seasoned therapists. This guide acts as a "cheat sheet" or template, providing a comprehensive framework for creating a full evaluation report that includes notes, SOAP, plan of care, and progress tracking for your patients.
Understanding Evaluation Vs. Examination
In the world of physical therapy, the terms 'evaluation' and 'examination' are often used interchangeably, leading to confusion. However, these two terms have distinct meanings. An evaluation cannot be completed without a thorough examination of the patient.
The clinical examination consists of:
Objective data collection
The PT evaluation is where the therapist communicates their findings, followed by a prescribed plan of care (POC). Think of a full evaluation as an in-depth SOAP note—the subjective, objective, assessment, and plan analyses for a patient’s treatment.
Before you begin the interview process with your patient, review the essential information such as their prescriptions, demographics, pain chart, past medical history, and current medications. Tools like digital patient intake forms can help collect this information ahead of time.
Consider administering a patient-related outcome measure (PROM) for valuable insights into the patient’s needs. This data can be collected before, during, or after the evaluation, depending on your workflow.
The Subjective Examination
The subjective examination is a critical part of the evaluation. It's where the clinical reasoning for the diagnosis and POC begins. It's so important that according to Nobel Peace Prize laureate Bernard Louw, medical history provides sufficient information in about 75% of patient encounters to make the diagnosis before performing a physical examination and additional tests.
The subjective examination should cover the following:
Chief patient complaints
Previous level of function
Mechanism of injury (MOI)
Employment and work history
Medical and surgical history
SINSS (severity, irritability, nature, stage, and stability regarding the patient’s condition)
Objective Measures in a Patient Examination
After collecting the subjective examination data, you can use all those skills you learned from PT school to gather relevant information pertaining to your patient’s primary complaint. These factors include:
Neighboring joints and systems screening
Active and passive range of motion collection
Muscle length testing
Manual muscle testing
Palpation and joint accessory motion testing
Additional outcome measures
With all the subjective and objective data in hand, it's time to compile it into a succinct assessment of the patient’s need for physical therapy. This assessment should also state the treatment diagnosis, prognosis, and goals.
The diagnosis should represent the injury or condition that you, the therapist, are treating. This treatment diagnosis will be identified by an ICD-10 code.
Provide a statement of the patient’s prognosis or "potential for rebab". This should include examples as to why you have assigned this prognosis. Some of these factors include motivation, comorbidities and past medical history, acuity of the injury or primary complaint, or nature of the dysfunction or related disease processes.
Goals for the patient to achieve as a result of skilled PT services must be included. Use SMART goals to ensure your patients’ goals are specific, measurable, attainable, realistic, and time-bound.
Plan of Care
The POC provides the evaluating PT a chance to describe how physical therapy is going to solve a particular patient’s functional problems. State the frequency and duration for which the patient will need services and the planned interventions you think will benefit this patient most in achieving their goals.
The final step in the evaluation process is to designate the complexity of the evaluation. There are three CPT codes that define complexities as low (97161), moderate (97162), or high (97163). To assist you in choosing the right code for a given case, five categories are used to qualify each level of complexity: Duration, History, Examination, Clinical presentation, and Decision making.
Physical Therapy Documentation Example
Brenda arrived at the therapy session, recounting an abrupt onset of calf discomfort following her recent participation in the "Brooklyn Half Marathon." She indicated that after an overly enthusiastic start, she experienced an immediate pull and cramp in her calf muscle, compelling her to walk for the remainder of the race:
Severity: Utilizing the visual analog scale (VAS), pain is presently rated at 3/10, at its worst was 6/10, and at its lowest is 1/10.
Irritability: Discomfort exacerbates while climbing stairs, stretching the calf, lowering to a sitting position, and running. The pain subsides with rest, ice application, and massage.
Nature: The pain seems to be mechanically induced.
Stage: The injury took place two weeks ago and is in the late acute healing phase.
Stability: Brenda reports a gradual improvement.
Brenda's past medical history includes anxiety, and hypertension. She scored 68/80 on the Lower Extremity Functional Scale (LEFS).
Objective Tests and Measures
Brenda's examination revealed the following deficits:
Brenda is experiencing pain and stiffness as a consequence of an acute strain to the medial gastrocnemius muscle sustained two weeks prior, with limited range of motion and strength in the lower limb, an abnormal gait pattern, and an inability to perform functional activities such as running, climbing stairs, and sitting on low surfaces. Skilled physical therapy services would be beneficial to address these impairments, restore normal ROM and strength in the lower limb, reduce pain, and enhance activity participation. Brenda's commitment to resume running and regain her pain-free level of function suggests an promising prognosis. Potential for rebab = Excellent.
Brenda's goals include:
Achieving at least 15 degrees of active and passive ROM into dorsiflexion to facilitate normalized heel strike at initial contact in three weeks.
In three weeks, Brenda will no longer experience pain while ascending stairs during an eight-hour work day.
Enhancing calf strength to perform 25 unilateral heel raises on the affected side for better propulsion while running and navigating stairs by six weeks.
Enhancing the LEFS score by a minimum of 9 points to match the minimal clinically important difference for a return to normal function by six weeks.
Plan of Care
To achieve these goals, Brenda would significantly benefit from skilled therapy, suggested twice a week for six weeks. Skilled PT interventions will comprise of:
Therapeutic exercise (97110);
Therapeutic activity (97530);
Neuromuscular re-education (97112);
Manual therapy (97140);
Gait training (97116);
Therapeutic modalities using cryotherapy and thermotherapy PRN (97010); and
Unattended electrical stimulation for pain control PRN (G0283).
Low complexity evaluation (97161) due to a 20-minute duration, a past medical history without any personal factors and/or comorbidities that could affect the POC, examination of body systems completed on one to two elements, the patient presents with a stable condition, and clinical decision making using the LEFS was of low complexity.
The Best Physical Therapy Documentation Software
Electronic Medical Records (EMR) software like PatientStudio offers a comprehensive solution to streamline the process of documentation in physical therapy. This software provides detailed note templates for PT Evaluations, Daily notes, and Progress notes, making the task of recording patient information more efficient and accurate. These templates are designed to capture all necessary data points, including patient history, examination findings, clinical decision-making processes, treatment plans, and progress updates.
PatientStudio EMR auto calculates units and charges, thereby eliminating the need for manual calculations and reducing the chances of errors. This functionality not only saves time but also enhances the accuracy of billing, ensuring proper reimbursement.
Moreover, PatientStudio EMR notes utilizes 'pull-forward' fields, which allow data from the evaluation note to be easily populated into the daily note. This feature eliminates redundancy and streamlines the data entry process, ensuring that all necessary information is carried forward accurately. By reducing the time spent on administrative tasks, therapists can focus more on their core duty - providing quality patient care.
Mastering the art of creating a thorough and effective Physical Therapy Evaluation note is a necessity in today's healthcare landscape. It forms the foundation of defensible documentation required for reimbursement. With this comprehensive guide serving as your cheat sheet, you'll be well on your way to creating evaluation notes that not only serve your patients but also meet the requirements set by insurers and regulators.
Remember, the most important aspect of physical therapy is human interaction. While digital tools like evaluation templates and digital intake forms can assist in PT documentation, the heart of your practice lies in the hands-on care you provide to your patients