APTA
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Solid documentation can demonstrate that you met or exceeded the standard care and can help you mitigate your risks.
Thorough documentation is a benefit and protection for both patients and clients and the clinician. It gives needed information to all providers involved with the individual's care in order to make informed decisions.
For physical therapists and physical therapist assistants, high-quality documentation provides a real-time, historical account of encounters with patients and clients, which can be an important source of evidence if care is ever called into question.
Article
CMS Updates Guidance to Reflect Current Plan of Care Signature ExceptionDec 3, 2025
A recent U.S. Centers for Medicare & Medicaid Services’ MLN Matters update provided guidance on a range of topics, including the plan of care signature
News
Updated UHC Language Confirms Policy Change on Documenting Treatment TimeJul 31, 2024
The latest update comes after clarifications the insurer released last year following a set of initially burdensome policy expansions.
News
Physical Therapy's Voice in Key Quality Measurement, Coding Groups GrowsSep 29, 2023
APTA members are informing key decisions in a rapidly evolving area of health care regulation.