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PT Documentation

The document outlines physiotherapy documentation guidelines, emphasizing accuracy, clarity, legibility, timeliness, and confidentiality. It details essential components such as initial assessments, treatment plans, progress notes, and discharge summaries, along with legal and ethical considerations. Additionally, it provides references for structured documentation formats and encourages adherence to professional standards.

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Ajas Km
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15 views5 pages

PT Documentation

The document outlines physiotherapy documentation guidelines, emphasizing accuracy, clarity, legibility, timeliness, and confidentiality. It details essential components such as initial assessments, treatment plans, progress notes, and discharge summaries, along with legal and ethical considerations. Additionally, it provides references for structured documentation formats and encourages adherence to professional standards.

Uploaded by

Ajas Km
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Absolutely!

Here's a detailed explanation of the physiotherapy documentation guidelines,


including why each component matters, how to document effectively, and what to
include under each heading:

🗂️1. General Principles of Documentation


These are the foundational rules for keeping physiotherapy records:

✅ Accuracy

 Record only what you’ve observed, measured, or what the patient reported.
 Avoid assumptions—stick to facts.
 Example: Instead of "patient seems better," write "patient reports decreased pain from
7/10 to 4/10 on VAS."

✅ Clarity

 Use simple, professional language.


 Avoid unnecessary medical jargon that might confuse others reading the file (e.g.,
interns or referring physicians).

✅ Legibility

 If handwritten, ensure it's readable. If digital, use structured templates and proper
formatting.

✅ Timeliness

 Notes should be written immediately or shortly after the session to avoid memory
errors.
 Delayed documentation can lead to legal issues or treatment errors.

✅ Confidentiality

 Store notes securely.


 Don’t share records unless legally required or with patient consent.
 Comply with laws like HIPAA (USA), GDPR (EU), or local privacy regulations.

📝 2. Components of Physiotherapy Documentation


Each part of the physiotherapy record has a clear purpose and content:
A. Initial Assessment

This section provides a baseline and helps guide treatment planning.

🧑 Patient Identification

 Name, age, sex, hospital/clinic ID, date of assessment


 Essential for tracking and avoiding mix-ups

📄 Referral Information

 Name of referring doctor (if any), reason for referral


 Helps understand medical context (e.g., post-operative rehab)

🗣️Subjective History

 Chief complaint: "Why are you here?"


 History of present illness: Onset, duration, progression
 Pain: Use scales (e.g., VAS/NPRS), describe location, nature (sharp, dull), timing,
aggravating/relieving factors
 Functional limitations: e.g., "Can't walk more than 10 minutes without pain"
 Previous treatment history: Medications, surgeries, therapies
 Lifestyle factors: Work, hobbies, physical activity

👀 Objective Examination

This section includes physical tests and observations:

 Observation: Posture, gait, swelling, deformities


 Palpation: Tenderness, temperature, muscle tone
 ROM: Measured with goniometer or visually estimated
 Muscle strength: Manual Muscle Testing (MMT)
 Neurological signs: Sensation, reflexes, coordination (if needed)
 Special tests: e.g., Straight leg raise, Phalen’s test
 Functional tests: Sit-to-stand, 6-minute walk, etc.

B. Assessment/Physiotherapy Diagnosis

 Clinical interpretation of findings


 Identify key problems: pain, weakness, loss of ROM, balance deficit
 Use the ICF model if possible:
o Body functions/structures: e.g., decreased ankle dorsiflexion
o Activity limitations: e.g., difficulty walking
o Participation restrictions: e.g., can't attend work
C. Goal Setting

Goals must be patient-centered and follow the SMART framework:

 Specific: Improve left knee flexion


 Measurable: From 60° to 120°
 Achievable: Based on condition and baseline
 Relevant: Helps patient return to function
 Time-bound: Within 4 weeks

Example:

"Patient will increase right shoulder abduction from 90° to 160° in 3 weeks to enable
overhead dressing."

D. Treatment Plan

Detailed plan based on diagnosis and goals:

 Intervention type: e.g., manual therapy, TENS, exercise therapy


 Frequency/duration: e.g., 3 sessions/week for 4 weeks
 Education: Ergonomics, posture correction
 Home Exercise Program (HEP): Clear instructions, frequency, reps
 Include rationale for chosen interventions

E. Progress Notes (Daily or Weekly)

Use the SOAP format:

🟡 S – Subjective

 What the patient reports


 e.g., "Patient says back pain is better in the morning but worsens after long sitting."

🟢 O – Objective

 Observations and reassessments


 e.g., "SLR improved from 30° to 60°, lumbar flexion increased by 10°."

🔵 A – Assessment

 Clinician’s interpretation of the session


 e.g., "Improved ROM indicates progress toward functional goal."

🟣 P – Plan
 What’s next? Continue or modify treatment?
 e.g., "Continue with strengthening exercises and add core stabilization."

F. Re-evaluation / Review

 Done every few weeks or at key milestones


 Repeat measurements (ROM, strength, pain)
 Compare with initial findings
 Modify goals if needed

G. Discharge Summary

 When treatment ends (goal achieved, referred, or patient quits)


 Include:
o Duration of care
o Goals achieved/not achieved
o Final outcomes (ROM, strength, function)
o Discharge instructions (home program, precautions)
o Follow-up advice

🔒 3. Legal and Ethical Guidelines


 Sign/date every entry (include designation, e.g., "PT")
 If a mistake is made:
o Cross with a single line, write “error,” and sign
 Standardized abbreviations: Helps others understand your notes
o Example: AROM = Active Range of Motion, MMT = Manual Muscle Testing
 Maintain records for 7–10 years (or as per regional law)

📚 4. Templates & References


If you want structured formats, refer to:

 APTA Documentation Guidelines (USA)


 CSP Record Keeping Guidelines (UK)
 WCPT Toolkit for Documentation
 Your local health ministry or hospital SOP
Would you like a printable template or sample notes for a specific condition like stroke,
ACL rehab, or back pain? I can create one tailored to your need.

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