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Physical Therapy Documentation of Patient and Client Management
Effective documentation isn't about your practice: it's part of it.
Clinical documentation of patient and client management is a professional responsibility and a legal requirement. But it's more than just a record of services provided and outcomes to support payment for services: documentation is critical to ensure that individuals receive appropriate, comprehensive, efficient, person-centered, and high-quality health care services throughout the episode of care.
The resources below are rooted in APTA Board of Directors guidelines and evidence-based best practices.
Documentation Elements
Access the main documentation elements: initial examination and evaluation, visit, reexamination, and conclusion of episode of care summary.
Setting-Specific Considerations
There are many elements of documentation that need consideration; one of the most important is clinical setting.
Risk Management
Solid documentation can demonstrate that you met or exceeded the standard care and can help you mitigate your risks.
Recommended Content
Apr 30, 2019 / Article
The following summarizes the documentation requirements required under Medicare Part B.
May 18, 2018 / Article
Many PTs find it difficult to document effectively while providing patient and client care.
May 18, 2018 / Article
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.
Additional Documentation Content
Sep 19, 2025 / News
Jul 31, 2024 / News
The latest update comes after clarifications the insurer released last year following a set of initially burdensome policy expansions.
Jun 28, 2024 / Article
Solid documentation can demonstrate that you met or exceeded the standard care and can help you mitigate your risks.
Sep 29, 2023 / News
APTA members are informing key decisions in a rapidly evolving area of health care regulation.
Mar 15, 2022 / News
Some providers who received phase 1 CARES Act funds are being told to return the money. Phase 2 recipients can still set things right.
Jan 1, 2022 / Article
Access considerations, guidelines, tools and resources to help you with general clinical decision-making in physical therapist practice.
Apr 1, 2021 / Column
Understand your legal obligations to your patients.
May 6, 2019 / Article
It helps to consider two questions: Why now? And why you?
Oct 1, 2018 / Column
"Documenting value-based care" simply means painting a clear picture of the good things you're doing as a PT.
Aug 30, 2018 / Policies & Bylaws
House position: The physical therapist has oversight of all documentation regardless of the setting in which physical therapist services are provided and shall comply with jurisdictional documentation requirements.