How does a PT document?

[skitd103]

I looked at APTA guidelines at http://www.apta.org/uploadedFiles/A...D/Practice/DocumentationPatientClientMgmt.pdf but I'm still a bit confused.

So for an initial vist the PT documents the Examination, Evaluation, Diagnosis, Prognosis, and Plan of care all in that day? Then for each subsequent visit do you just use the SOAP format? Is it this way for every PT setting? And lastly, are there standard forms you fill out for this or is it up to the PT?

Thank you!

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[goyo1010]

Are you already a working PT from another country asking how documentation works in the US (you indicate "DPT or ODT" as your status)?

Documentation differs from setting to setting. Some places use a template that may or may not follow the SOAP note format. This template may be in the form of a paper evaluation form/progress note form, or an electronic copy with dropdown menus and checkboxes. Other places may use an EMR or hand-written notes in SOAP note format. However, your initial evaluation should contain relevant PMH, appropriate subjective information, all your objective findings, your assessment of the patient and his or her rehab potential from those findings, and finally, your POC. Your progress note will be more noticeably shorter, recording any relevant subjective, recording what was done during the tx session, and your assessment of the pt's performance, progress, etc, and what you plan to do next session.

 

[skitd103]

Nope, just a curious student! I'm not sure why I put that as my status back when I joined, maybe I thought it pertained to our interest. Thank you for your help though!