Documentation of a visit may include the following:

• Patient or client, or caregiver, report.
• Interventions provided, including frequency, intensity, time, duration, and level of physical and/or cognitive assistance provided as appropriate (see discussion of support for timed interventions below). Examples include:
  • Right knee extension, 3 sets, 10 repetitions, 10-pound weight, full range with 100% manual cues to facilitate use of medial quad and 50% verbal cues for timing
  • Transfer training bed to chair with sliding board; required moderate physical assist of 1 and 100% verbal cues for placement of board
  • Description of equipment provided (sliding board, long handles sponge) for home use
  • Description of education or training provided (Patient educated in proper lifting technique from floor to chest height and able to demonstrate technique with up to 25 pounds)
   
• Patient or client response to treatments. Do not use "patient tolerated treatment well." Describe the response, such as "heart rate increased to 90 beats/minute; blood pressure response; movement exhibited decreased endurance and increased pain."
• Communication and collaboration with other providers, patient or client, and family, caregiver, and significant other as applicable or indicated. These communications may sometimes be verbal orders in an inpatient or outpatient setting. Depending on the practice setting, you should check with the policies and procedures of the clinic or facility, state practice act, and payer requirements to determine if there are any procedures for documenting verbal orders in a patient's or client's record. In addition, facilities or practices accredited by an agency such as CARF, CHAPS, or The Joint Commission may be subject to those agencies' particular compliance standards. Medicare's hospital conditions of participation also include procedures for documenting verbal orders.
• Verbal communication other than orders, including phone calls or contact with the patient or client, his or her family or other caregiver, a patient's or client's other health care provider, and any other professionals involved in the individual's care also should be documented.
• Factors that modify frequency or intensity of intervention and progression within the plan of care (only performed by PT).
• Plan for next visit(s) including interventions with objectives, progression parameters, and precautions, if indicated within the physical therapist plan of care.

Note: Even cancellations and "no shows" should be documented, with a date and note that the patient canceled or did not show for the appointment, and the reason, if any—or that no reason was given. Also note if the appointment was rescheduled, with the new date.

Just the links below to jump down to the topic of interest.

• How to Convey Skilled Interventions in Daily Notes
• How to Communicate Progression of Care and Ongoing Assessment in Daily Notes
• Progress Reports
• Support for Timed Interventions
• Caution: SOAP Notes and Flow Sheets
• Skilled Maintenance: Demonstrating Skilled Therapy for Maintenance or Lack of Progress

Conveying Medical Necessity and Skilled Intervention in Daily Notes

It is important to convey in the documentation of a visit (ie, daily note) that the interventions provided require the skills of a physical therapist, or of a physical therapist assistant under the direction and supervision of a physical therapist (see APTA's resources on Supervision and Teamwork). The daily note is not just a listing of what treatments took place. While it is important to include the interventions provided, this does not demonstrate skilled care. In addition, PTs should document the type and level of skilled assistance given to the patient or client, the PT's clinical decision making and/or the PTA's problem solving, and continued analysis of the individual's progress or lack of progress. The PT or PTA can express this by recording both the type and amount of manual, visual, or verbal cues used to assist the individual in completing the exercise or activity completely and correctly. In addition, the PT can document why the interventions were chosen and/or why they are still necessary.

Some ways of demonstrating skilled care include documenting what the PT observes before, during, and after an intervention; the individual's specific response to the intervention; and functional progress. The interventions should correlate to the impairment, activity limitation, participation restriction, and the goals stated in the plan of care.

Consider these examples:

• Patient required verbal and manual cues to complete shoulder flexion and abduction exercises without substitution. Therapeutic exercise and right shoulder mobilization resulted in increased flexion from 90° to 110° allowing the patient to reach overhead and complete activities of daily living. Patient still unable to perform overhead activities needed in performance of job duties.
• Patient required moderate verbal and manual cues to control movement of right leg in swing phase of gait. Therapeutic exercise to hip flexors, extensors and knee flexors, extensors at 50% of 1 repetition max has resulted in increased strength. Patient still demonstrates inability to clear right foot 100% of the time during gait, increasing risk for falls.

When a clinician documents an assessment as "patient tolerated treatment well," it does not provide evidence of skilled services. In addition, it does not give enough information regarding your clinical decision making or problem solving to demonstrate what actually happened if this visit were to be called into question in a legal case.

For Pediatric Patients and Clients

In pediatrics, especially school-based practice, there may be some misconception that daily notes are not required. However, skilled physical therapist intervention should be documented for each visit. In skilled nursing facility settings, there may not be payer-specific requirements for daily notes. However, it is best practice for clinicians to have a system in place to track what skilled interventions were provided in daily treatments and why those treatments required the skills of a physical therapist or physical therapist assistant, so that when the weekly note or progress report is written, there is enough evidence to complete the documentation efficiently and completely.

Unsubstantiated evidence of medical necessity and skilled care are 2 of the most common reasons for payment denial in physical therapy. According to most third-party payers, every patient or client visit must be both medically necessary and require skilled intervention. To effectively establish medical necessity, the documentation must clearly indicate why intervention is indicated at the current time. Evidence of skilled service must reflect why the skills of a therapist are required to deliver the necessary intervention versus another provider. Evidence of these 2 elements is expected in the PT's documentation. Documentation of skilled services is also discussed in the section on "Visit/ Encounter Notes."

Suggestions for how a physical therapist might support these 2 elements in clinical documentation include:

• Provide a brief assessment of the patient's/client's response to the intervention(s) at every visit or event.
• Document your clinical decision making process. For instance, explain why you changed the patient's/client's exercise program, added or discontinued a modality, or progressed a functional activity.
• Make sure documentation is not repetitive, restating the same thing day after day.
• Make sure that when you reread your own documentation, there is no doubt that only a skilled physical therapist could have provided the treatment.

Suggestions for how a physical therapist assistant might support these 2 elements in clinical documentation include:

• Document how the patient/client tolerated the intervention(s) at every visit or event.
• Document how specific exercises or activities will help the patient/client achieve a goal.
• Make sure documentation is not repetitive, re-stating the same thing day after day.
• Make sure that when you re-read your own documentation, there is no doubt that only a skilled physical therapist assistant could have provided the treatment.

Whenever a payer requests documentation for a particular date of service, review the note(s). It may be necessary to send supporting documentation for additional dates of service, such as the most recent summary of progress or reevaluation, so the payer can fully appreciate the context in which that date of service was provided.

How to Communicate Progression of Care and Ongoing Assessment in Daily Notes

At its most basic level, a daily note serves as a record of all treatments and skilled interventions provided along with the time of the services, providing justification for the services billed on the claim form. For each daily note, there could also be a notation as to any changes in the impairments, activity limitations, and participation restrictions as a result of the interventions, and any progress toward the goals and, ultimately, toward conclusion of care. (As noted earlier, some payer guidelines restrict a physical therapist assistant from documenting this information.) If any measurements are taken, they should be recorded and relate back to the achievement or lack of achievement toward the functional goals. When a physical therapist is completing the daily notes, and the ongoing assessment is demonstrated, frequently with this level of detail a progress summary or progress report (see next section) may not be required.

Progress Reports

A progress note or progress report or summary is often referred to in third-party payer, state, and facility regulations. The progress report or summary is similar to a daily note but includes more detailed information on the patient's or client's current status compared with a previous date(s) (eg, date of initial evaluation, last reexamination, or last progress report). In most cases, important changes in examination findings are described. Note that the daily notes and progress reports or summaries work together. If progress is described in daily notes, then a progress report or summary may not be necessary. This is particularly true for shorter or less intense episodes of care.

Physical therapists may choose to title certain daily notes as progress reports or summaries and include this level of detail in 1 place. Progress reports or summaries should be performed regularly on all patients or clients to substantiate the ongoing need for physical therapist services. The report should provide an update on the individual's status as it relates to the physical therapist goals and plan of care.

Only the PT can write a note that requires assessment of the patient or client and his or her progression or lack of progression. PTAs cannot write this type of assessment as noted in APTA policy, Medicare regulations, other third-party payer rules, and state law. However, the PT may use data gathered by PTAs to include in the note.

For Pediatric Patients and Clients

In early intervention, a team progress report is provided on a 6-month basis when the team reviews the IFSP. In this review, the family and pediatric patient's progress toward their outcomes and objectives are noted, and the plan of care is revised as indicated. In school-based practice, progress reports to parents are required on the same frequency that parents receive reports on academic progress.

In the home health setting, a progress report is required as part of the recertification process if services are going to continue beyond the current 60-day episode of care. Recertification must be completed within the last 5 days of the current certification period. There is also a requirement of individual notes for every patient encounter.

In skilled nursing facilities, a weekly progress note may be the only required documentation. The physical therapist and physical therapist assistant should collaborate on the information presented in the weekly note to ensure the information supports the skilled nature of the services provided during the week and provides objective evidence of progress or lack of progress toward goals. The PT should complete any further assessment of potentially needed changes to the plan of care.

Support for Timed Interventions

PTs and PTAs are required in many settings to support the reporting of timed procedure and modality codes in their clinical documentation. This requirement derives from the CPT code definitions for procedures and modalities reported by physical therapists. The time reported should reflect direct 1-on-1 contact time with the patient or client (ie, Medicare requires documentation of total treatment time spent on timed and untimed codes). If the setting does not use CPT coding, such as Medicare Part A for hospital inpatient or skilled nursing facilities, or home health, then the documentation must substantiate the total visit time.

More Information

• Medicare regulations on timed codes and documentation of time
• Medicare physician fee schedule
• Skilled nursing facility settings
• Hospital settings
• Medicaid regulations may have specific language on documentation for each state

Caution: SOAP Notes and Flowsheets

Many physical therapists choose to document in a standard SOAP note format for their daily notes and progress notes. While commonly used in clinical practice, SOAP notes are often incomplete. If a PT uses the SOAP format, the following guidelines are recommended:

S: Subjective: This should reflect the patient's or client's (and at times caregiver's) self-report of status and response to previous treatment(s). Some tests and measures that are subjective may be included in the subjective portion of the SOAP note (eg, self-report such as SF-36).

O: Objective: This should reflect the physical therapist's objective findings made through observation of the individual, as well as tests and measurements (eg, circumferential measurements for edema, range of motion measurements, 6-minute walk test, or heart rate before and after exercise). The treatment provided to the individual and the response to treatment on that specific date also should be included in this category, but it should not be in place of objective data.

A: Assessment: This should reflect the PT's clinical decision making and/or the PTA's clinical problem solving, including their professional assessment of the patient's progress, response to therapy, remaining impairments, activity limitations, participation restrictions, and possible precautions. This should not be documented as "treatment tolerated well."

P: Plan: The PT should provide specific information related to the plan for future services including patient or client, or caregiver, education and any possible changes in the treatment program. Do not simply say "continue."

Flowsheets are another common form of documentation for daily notes. While they may be a useful format to note specific interventions such as exercises, and parameters such as repetitions and weights, flow sheets often lack space for the PT to include the elements that made those interventions skilled treatment, as well as the assessment of the individual's status and plans for ongoing care. Evidence of skilled decision making and other critical factors should be included in the daily documentation. 

SOAP Notes: Pros and Cons

¹A Payer's Guide to Physical Therapy Documentation for Patient/Client Management. Alexandria, VA: American Physical Therapy Association; 2006.

Skilled Maintenance: Demonstrating Skilled Therapy for Maintenance or Lack of Progress

There has been a longstanding myth that Medicare does not cover services to maintain or manage a beneficiary's current condition when no functional improvement is possible. The 2013 Jimmo v Sebelius final settlement sought to dispel this fallacy and provide clarifications to safeguard against unfair denials by Medicare contractors for skilled therapy services that aid in maintaining a patient's current condition or to prevent or slow decline. In January 2014, the Centers for Medicare and Medicaid Services (CMS) issued revised portions of the Medicare benefits policy and claims processing manuals (.pdf) to clarify coverage of skilled therapy services in maintenance care. CMS reiterated its longstanding policy that skilled therapy services still may be covered even in situations where no improvement is expected, including when skilled services are needed to prevent deterioration. CMS provided further clarification in a 2017 webpage dedicated to the Jimmo settlement.

Medicare states that coverage depends not on the beneficiary's restoration potential but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves.

Documentation, then, on the need for medically necessary skilled therapy services, is critical. It is important that the PT's documentation shows the following:

• Skilled involvement is required for the services to be provided safely and effectively.
• The services themselves are reasonable and necessary for the treatment of a patient's illness or injury.
• The services are consistent with the nature and severity of the individual's illness or injury, the individual's particular medical needs, and accepted standards of medical practice.
• The frequency and duration of the services provided are appropriate and support the documented clinical goals.

CMS differentiates between "restorative or rehabilitative" therapy and "maintenance" therapy. In the case of rehabilitative therapy, the patient's condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained, and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.

In the case of maintenance therapy, the skills of a therapist are necessary to maintain, prevent, or slow further deterioration of the patient's functional status, and the services cannot be safely and effectively carried out by the patient alone or with the assistance of nontherapists, including unskilled caregivers.

When rehabilitative or maintenance therapy is provided, it is expected that the documentation in the patient's medical record will reflect the need for the skilled services. The patient's medical record is also expected to provide important communication among all members of the care team related to the development, course, and outcomes of the skilled examinations, evaluations, interventions, and training performed. The documentation should explain the degree to which the patient is accomplishing the goals as outlined in the plan of care. In this way, the documentation will demonstrate why skilled services are needed.

CMS also states that the presence of appropriate documentation is not, in and of itself, an element of the definition of a "skilled" service. Documentation serves as the means by which a provider establishes, and a contractor confirms, that skilled care was needed and provided to the patient.

Based on the CMS documentation guidance, the documentation must include, as appropriate, these 7 items:

1. The history and physical exam pertinent to the patient's care, (including the response or changes in behavior to previously administered skilled services). Documentation includes the patient's previous and current levels of function using valid functional or performance-based tests.
2. The skilled services provided. Provision of a treatment by a physical therapist does not by itself constitute skilled care. Documentation includes details of the intervention and why the PT's services were needed (eg, "provided verbal or tactile cues," "monitored heart and respiratory rate," "provided assistance for safety and balance"). In the home health and outpatient settings, physical therapist assistants are excluded from providing skilled maintenance under Medicare rules.
3. The patient's response to the skilled services provided during the current visit. Instead of "treatment tolerated well," documentation describes the response of the patient to the intervention ("patient's heart rate increased," "patient required frequent rest periods," "pain increased [or decreased] after treatment").
4. The plan for future care based on the rationale of prior results. Documentation includes the PT's plan for the next visit based on the response of the patient at the current visit ("increase the number of stairs to 10 negotiated with a single cane," "perform transfer training from the wheelchair to the car with instructions to caregiver"). This will also help another therapist if the treating PT is absent for the next visit.
5. A detailed rationale that explains the need for the skilled service in light of the patient's overall medical condition and experiences. For example, "due to an unstable fracture, the skills of a PT are needed to perform functional activity for safety."
6. The complexity of the service to be performed. For example, "dynamic balance was performed during gait training with tactile cues and assistance for safety. This could not be performed with a nonskilled caregiver."
7. Any other pertinent characteristics of the patient that may impact the PT's plan of care or the outcome of care. A service is not skilled care just because a nonskilled caregiver is not available to provide it. For example, a patient lives alone and is responsible for his own ADL and meal preparation, but he has no nearby relatives and cannot afford a caregiver. If the PT provides these otherwise nonskilled services in the absence of a caregiver, the services would not now be considered skilled care.

Physical therapists typically have documented goals in functional, measurable terms that indicate the predicted level of improvement in function. However, goals can also be written to demonstrate to both the individual and the payer how interventions will directly affect the individual's physical status—the impairments, activity limitations, and participation restrictions even if progress is not anticipated. Inclusion of coordination and communication with others and patient or client-related instruction can also be included in the goals.

When skilled services are necessary to maintain the patient's or client's current condition, the documentation must show that the PT's services are required to achieve this goal. To establish that the maintenance program's services are reasonable and necessary, documentation should reflect the degree to which the goals are being accomplished. If the goal is to maintain an individual's current condition, then the documentation should reflect the maintenance program's effectiveness in achieving this goal. If the goal is to slow further deterioration of the condition, the documentation should reflect that the natural progression of the individual's medical or functional decline has been slowed. Use the goals as a roadmap to determine if the goals are being met or need to be adjusted.

Consider what was done in the visit that required the skills of a PT or PTA, as opposed to another provider or caregiver. What knowledge, training and skills were used to provide the intervention?

Consider these examples:

• Skilled: Provided transfer training from sit to stand. Patient requires tactile and verbal cues to facilitate trunk flexion.
  
  Nonskilled: Patient attempted to get out of chair independently. Noted difficulty getting to edge of chair. Multiple attempts required to come to standing position.
• Skilled: Moderate assistance provided with gait training to compensate for left sided neglect and assist with weight shifting for proper progression of bilateral lower extremities. Patient able to demonstrate ambulation 30' x 1 with standard walker.
  
  Nonskilled: Gait training – patient ambulated with standard walker.
• Skilled: Prior to activity HR- 83 BP- 128/89 and SaO2 – 98% on room air. Patient monitored during the following activities: bike x 15' followed by treadmill x 10' at 3.0 mph. Patient's vital signs after activity as follows: HR- 123 BP- 146/89 and SaO2 – 89% on room air. Patient also visibly fatigued and short of breath. After 5' rest, vital signs returned to baseline.
  
  Nonskilled: Bike x 15' followed by treadmill x 10' at 3.0 followed by therapeutic exercises per flow sheet.