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Introduction

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Documentation is vital to the role of the physical therapist and physical therapist assistant.1 This book is designed to teach students and new practitioners about health records and physical therapy documentation within health records.

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Sections of This Textbook

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The process of clinical decision-making, and documenting clinical decision-making, begins with the health record. Part I of this textbook provides background information that every health professional needs on the health record, legal aspects of the health record, and reimbursement. Part I concludes with a chapter on reviewing the health record as a physical therapist.

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Part II provides information on the basics of documentation: how to write in a health record, the types of notes used by physical therapists, abbreviations and terminology, and an introduction to the International Classification of Functioning, Disability and Health (ICF).

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Part III explores how to document the patient examination and introduces the first parts of the Patient/Client Management note and SOAP notes. Documenting clinical decision-making in the patient evaluation or assessment is introduced in Part IV. Part V explains how to document the Plan of Care. Part VI addresses the daily note and documentation formats in specialized circumstances. Appendices A through D summarize information from the text into a short form that can be useful in a clinical setting.

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How to Use This Book

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This book was written to help student practitioners learn the skill of writing patient care notes. Like any other skill, writing notes takes practice. We provide an opportunity for you to practice by completing the worksheets at the end of many of the chapters. (The chapters in Part I and a few other chapters do not have worksheets, as they cover prerequisite, background material needed for good documentation in general.)

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The benefits derived from completing the worksheets in this textbook depend upon you. Learning to write notes in patient care requires practice, just as learning new patient care skills requires practice. By completing the worksheets and then comparing your work with the answers your instructor provides, you will learn in the same manner that learning takes place in the clinic. Individual practice and feedback have always proved to be the best methods of learning to write notes. If you are a novice at documentation, it is very important that you complete each worksheet before you look at the answers online. There are as many variations to note writing as there are practitioners. If your answers are not exactly the same as those provided, consider whether your answers would be acceptable and why the answers given might or might not be preferable to your answers.

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Abbreviations

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Chapter 9, “Using Abbreviations,” introduces the abbreviations most commonly seen and/or used by therapists. The abbreviations listed for XYZ Healthcare Center, the healthcare facility in which we are ...

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