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INTRODUCTION

This is a sample documentation review checklist only. Check with the payer, state law, and the applicable accreditation organization, such as The Joint Commission and Commission on Accreditation of Rehabilitation Facilities (CARF), for specific compliance requirements.

Therapist reviewed: Date:

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REVIEW OF MEDICAL RECORDS DOCUMENTATION FOR PHYSICAL THERAPY
PHYSICAL THERAPIST INITIAL VISIT ELEMENTS FOR DOCUMENTATION
Examination YES NO N/A
  • 1. Date/time

  • 2. Legibility

  • 3. Referral mechanism by which physical therapy services are initiated

  • 4. History: medical/surgical history, past physical therapy, social history, growth order and development, living environment, work status, cultural preferences, current condition(s)/chief complaint(s), onset, previous functional status and activity level, medications, allergies

  • Review of systems: cardiovascular and pulmonary; endocrine; eyes, ears, nose, throat; gastrointestinal; genitourinary and reproductive; hematologic and lymphatic; integumentary, musculoskeletal, neuromuscular

  • 5. Patient's or client's rating of health status, current complaints

  • 6. Systems Review: brief, limited exam of musculoskeletal, neuromuscular, cardiovascular/pulmonary, and integumentary systems that may or may not be related to chief complaint, and may require outside consultation or referral; also may include patient's or client's communication ability, cognition, factors that might influence care, language, learning style

  • 7. Tests and Measures: specific tests and measures used, with emphasis on standardized tests (such as OPTIMAL and Oswestry); associated findings or outcomes

Evaluation YES NO N/A
  • 1. Synthesis of the data and findings gathered from the examination, highlighting pertinent factors; level of severity; should guide the diagnosis and prognosis; formats could include a problem list or statement of assessment of key factors that influence patient or client status (such as cognitive factors, comorbidities, social support, additional services)

Diagnosis YES NO N/A
  • 1. Made at the levels of impairment of body function and structure, activities and participations, and health conditions; uses common terminology such as ICD-10-CM diagnostic coding system; includes impact of condition on movement

Prognosis YES NO N/A
  • 1. Conveys the PT's professional judgment on the predicted functional outcome and estimated duration and intensity of services to achieve the desired outcome

Plan of Care YES NO N/A
  • 1. Overall goals stated in measurable terms that indicate the predicted level of improvement in function over the entire episode of care

  • 2. Statement of interventions to be used; whether a PTA will provide some interventions; physical therapist of record

  • 3. Proposed duration and frequency of services to reach desired goals (such as number of visits per week, number of weeks)

  • 4. Anticipated discharge plans

Authentication YES NO N/A
  • 1. Signature, title, and license number (if required by state law)

Physical Therapist Daily Visit Note Elements for Documentation

Yes

NO

N/A

  • 1. Date

  • 2. Cancellations and no-shows

  • 3. Patient or client, or caregiver self-report (as appropriate) and subjective response to previous treatment

  • 4. Identification of specific interventions and/or equipment provided, including frequency, intensity, and duration as appropriate

  • 5. Changes in patient or client status in terms of impairment, functional limitation, and disability status as they ...

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