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Learn how to document patient and client management effectively and legally with APTA's evidence-based best practices and resources. Find tips, tools, and articles on documentation elements, setting-specific considerations, risk management, and more.
Documentation Authority For Physical Therapy Services Physical therapy examination, evaluation, diagnosis, prognosis, and plan of care (including interventions) shall be documented, dated, and authenticated by the physical therapist who performs the service.
Our tips include the top 10 payer complaints about documentation (reasons for denials) and tips for improving documenation efficiency, plus terms to avoid and more. Log in or create a free account to keep reading.
Learn how to document a visit in physical therapy, including changes in status, interventions, and communication. Find out the recommended format, abbreviations, and tips for documentation of a visit.
The following summarizes the documentation requirements required under Medicare Part B. Please refer to CMS’ Medicare Benefit Policy Manual Chapter 15 Section 220.3 for detailed guidance on Medicare’s documentation requirements.
Learn about the concept, elements, and best practices of defensible documentation for physical therapists and physical therapist assistants. Find tips, checklists, publications, and more on APTA's updated webpage.
In this 45-minute recorded webinar, APTA staff review Medicare’s physical therapy documentation requirements and discuss documentation best practices. They discuss how to overcome the documentation concerns reported by payers and review some of the standardized tests that assist physical therapists in quantifying documentation and goals.
Learn how thorough documentation can benefit and protect both patients and clinicians, and demonstrate standard care. This article is for physical therapists and physical therapist assistants, and requires a free account or APTA membership to access.
Learn how to document the initial physical therapist visit, which consists of an examination and evaluation. The article covers the elements of documentation, such as diagnosis, prognosis, intervention, and outcomes.
Learn how to use the CPT codes 97161, 97162, 97163, and 97164 for physical therapy evaluation and reevaluation. Find the requirements, components, and definitions for each code level and the typical face-to-face time.