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Therapy Documentation - Physical Therapy Documentation

Therapy documentation is a very important part of physical therapy (PT) practice. There are several types of physical therapy documentation ranging from a full initial evaluation during the first client visit to everyday encounter or treatment notes called the daily SOAP notes or quick notes.

SOAP Format

Most therapy documentation follow the SOAP format. SOAP stands for subjective, objective, assessment and plan. This format is typically seen in the initial evaluation, daily progress notes, re-evaluation, among others.

Therapy Abbreviations and Symbols

In clinical physical therapy documentation, physical therapists use different abbreviations and PT symbols that can make PT notes writing faster and more concise.

Physical Therapy Documentation Software

Therapy documentation has been made easier, faster and more error free, thanks to physical therapy softwares available today. What these softwares do is they make your documentation faster, giving you more available time for your client, concentrating on their exercises and treatment including patient education.

Most physical therapy softwares have several features including:

  • Client/patient scheduling
  • Document templates where information can be easily put with the click of a button. Some are easily customized according to documentation and treatment protocols.
  • Integrated physical therapy billing software that is compliant with rehabilitation standards.

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