Creating informative, legally compliant physical therapy documentation can be tricky for practitioners who are just starting to deliver their services online. Without paper templates, there’s always the worry of missing important details, ICD codes, or how you’ll outline your prescriptions with clarity.
But switching to digital physical therapy forms is a huge time-saver for professionals and practices in the long run – with specialized Physical Therapy software, many common forms, such as Therapy Intake forms and Progress Notes, are already provided for you to customize and use with clients. This article covers the essential elements of the most vital PT forms with examples and templates so that you can easily create your own.
Physical Therapy Documentation: 3 Examples
Across PT sub-disciplines, there are different standards for official physical therapy documentation. But whether you practice pediatrics, orthopedics, or neurological therapy, best-practice guidelines and examples are an effective way to ensure your notes are useful and complete.
These physical therapy documentation examples can help you deliver comprehensive, efficient, client-centered, and high-caliber PT services while creating records for insurance and physical therapy billing purposes.
Using these to create standard templates within your software will save you from replicating standard documents such as Therapy Intake forms every time you treat a patient. The best physiotherapy software will allow you to customize these for different patients and treatment plans, so you are always providing a personal service for each patient or client.
- The American Physical Therapy Association (APTA) has created a useful guide entitled Elements of Documentation within the Patient/Client Model covering all the main components of PT documents. Starting with Initial Examination and moving through Visit and Reexamination to Discharge Summary, it gives examples of what each section should include, such as patient history, systems review, and plan of care. This resource includes narrative, pediatric narrative, and problem list examples to help practitioners create high-quality PT forms that meet national standards for best practice.
- The APTA also provides a more general Guide to Physical Therapist Practice to help practitioners in the profession and contains examples for how to sign documents, document patient status or progress, and create reexamination or reevaluation notes for treatment plans. These general standards apply to all practitioners. They can be a good point of reference for creating Therapy Progress Notes, consultation notes, and provision of care flowsheets.
- The European Union’s World Physiotherapy also provides guidelines for practitioners to refer to when creating or choosing standard templates for their practice systems. Its Quality Assurance Standards of Physiotherapy Practice and Delivery can be used as a handy checklist for creating digital physical therapy documents such as intervention records. Some examples of PT form checklist items include chronological ordering, date and time indicated for each intervention, and a signature or e-signature to formalize your report. With specialty-specific software or modules, pre-designed or custom forms should follow these physical therapy guidelines to reduce practitioner errors and legally protect a practice.
PT Intake and Evaluation Forms: 2 Templates
Providing an electronic PT Intake Form on your practice website or through a private Client Portal is a smoother, more efficient way to onboard new clients.
When setting up your online practice as a blended care physiotherapist, PT Intake Forms will likely be the first thing you create or make available for digital download.
After this, PT Evaluation forms are often the most frequently used and can reduce your admin workload hugely when digitalized.
Providing an electronic PT Intake Form on your practice website or through a private Client Portal is a smooth and efficient way to onboard new clients. They’ll be able to give you all their important information in their own time before treatment, while the details are stored in a centralized place for quicker admin access, in a way that’s fully HIPAA-compliant.
Whether you’re building your own PT Intake or Evaluation form from a custom builder within your software, or you’re choosing from a library of physical therapy documentation, these templates can be used to structure your document.
PT Intake Form Template
This PT Intake Form template outlines what a digital document should include and can be used as a checklist when creating your own Intake Form in a custom form builder.
Physical Therapy Intake Form Template
Terms and Conditions
Insurance Information and Consent
Further Practice Information
Different sub-specialties and practices will have different assessment questions and policies, which is why free-text fields and customizable drop-down menus are handy when designing your own PT Intake document. These allow you to enter your own verbiage and statements, which patients can quickly and easily sign below.
PT Evaluation Form Template
Evaluation forms are often included in PT Intake documentation, but this framework can be helpful for a closer look at the essentials.
Creating your own PT Evaluation Form Template with this general guide gives you the flexibility to create your own options with multiple-choice questions and more.
Physical Therapy Evaluation Form Template
Body Chart/Anatomical Diagram
The screengrab shows how this might look in an online format. Here, PTs can quickly and easily enter assessment notes about pain and symptoms alongside the relevant body chart. The completed form will then be saved in the physical therapy software for convenient access by other providers:
In our Quenza example, a PT can add custom fields depending on the particular needs of a certain patient with the software’s Activity Builder.
Blended Care: 4 Digital Solutions To Look Into
Not all physical therapy documentation needs to be built from scratch – especially in PT software, which often comes equipped with a library of pre-designed, professional forms and all the tools required to customize specific fields.
The right software for your practice should ideally save practitioner time and improve the quality of your completed documents for better multi-provider communication with commonly used medical codes and complaints.
Other useful features include e-signatures and locking capabilities to safeguard your physical therapy records, HIPAA-compliant document storage, and even multimedia libraries for video coaching patients through popular exercises and HEPs.
|DrChrono is a specialized suite of physical therapy tools for busy practitioners and surgeries. With invoicing features, videoconferencing, therapy notes templates, and other practice management functions, it includes a vast library of progress note templates and other physical therapy forms.HIPAA-compliant for secure therapy notes and telehealth sessions, this platform offers an efficient way to customize and share Therapy Intake Forms, with specialized fields for specifics like pain severity range of motion and diagrams. DrChrono also includes take-home exercise programs and more to save time when designing treatment plans.|
|Price||Varies with solution|
|Good For||Physical Therapy Forms, Physical Therapy Billing, EMR/EHR, Treatment Planning, Practice Management|
|Quenza is an all-in-one PT software that takes care of multiple functions, from treatment planning and practice management to client engagement, patient outreach, assessment, and beyond.To create physical therapy forms such as Intake Assessments, Informed Consent, Evaluations, Quenza has a user-friendly Activity Builder equipped with drag-and-drop functionality, multimedia support, and a range of different field types (e.g. free text, multiple-choice, checkboxes, and more). It also includes a sizable Expansion Library full of customizable templates, which can be modified to save time.|
The software also comes with a useful Pathways feature that can be used to assemble interventions and activities into treatment plans; these can be scheduled and automatically sent to patients via a free, HIPAA-compliant mobile client app. Quenza comes with a $1, 1-month trial plan for practitioners.
|Good For||Physical Therapy Forms, Physical Therapy Billing, Treatment Planning, Practice Management, Video Coaching, Video Therapy, Care Management|
|With free text fields, point-and-click functionality, speed entry, and specialty-specific codes, WebPT is a great solution for physical therapists looking to create better documentation. The software offers ICD and CPT codes, outcome tracking tools for progress evaluation, and PT billing features to help practitioners monitor compliance while supporting outpatient treatment.WebPT also comes with modules for different physical therapy sub-disciplines such as pediatrics, pelvic health, wellness care, neuro, and vestibular. All correspondence can be branded with your corporate imagery for a professional touch.|
|Price||$3+ daily per provider|
|Good For||Physical Therapy Forms, Physical Therapy Billing, EMR/EHR, Treatment Planning, Practice Management, Marketing|
|All-in-one digital health platform Kareo offers specialty-specific physical therapy documentation tools for faster, more accurate forms and templates. Physiotherapists can create personalized progress notes, prescriptions, exercise programs, and admin documents using the software’s inbuilt tools or through integration with WebPT.Therapists can design, amend, and share treatment plans for clients using preconfigured fields specific to PT, and Kareo also processes insurance superbills, generates practice reports, and supports secure client messaging.|
|Price||Available on request|
|Good For||Physical Therapy Forms, Physical Therapy Billing, EMR/EHR, Treatment Planning, Practice Management|
Going digital with PT documentation can be hugely rewarding – with a little setup, electronic forms can improve your efficiency and free you up to spend more time with clients.
With solid know-how on what various physical therapy forms should include, you can easily create your own forms to customize, brand, and share with clients while cutting down the paperwork burden for your admin and medical staff.
We hope you enjoyed reading this article. Why not use your Quenza $1 trial plan to turn our tips and templates into professional physical therapy forms for your own blended care practice?
Quenza is designed to help you enhance your patient experience and outcomes as a PT, and will give you all the tools you need to enhance their successes for the long term.
- ^ APTA. (2018). Elements of Documentation within the Patient/Client Model. Retrieved from https://www.apta.org/your-practice/documentation/defensible-documentation/elements-within-the-patientclient-management-model
- ^ APTA. (1997). Guide to Physical Therapist Practice. Retrieved from https://academic.oup.com/ptj/article-pdf/77/11/1634/30107800/ptj1634.pdf
- ^ Europe Region WorldPhysio. (2020). Quality Assurance Standards of Physiotherapy Practice and Delivery. Retrieved from https://www.erwcpt.eu/physiotherapy_and_practice/standards_of_practice