Physical Therapy Documentation Examples (Downloadable) and Best Practices with Physical Therapy Forms

physical therapy documentation examples, physical therapy forms, physical therapy documentation samplesAt In Touch EMR, we get daily calls from clinicians, owners and students asking us for physical therapy documentation examples that qualify as ‘defensible documentation’.

Here’s a thought – why do we need to be ‘defensive’ with our documentation?

Why can’t we just focus on patient treatment, and not be burdened by endless documentation?

It’s a valid notion, but the reality of reimbursements leaves us no choice. It forces us to document.

The purpose of documentation is to demonstrate intent, the intent to bill certain codes and get paid by an insurance company.

As best practice, rendering providers should have a basic understanding of compliant documentation, and how insurance payments work since they generate the claims. The clinician handles visual, verbal or manual contact with the patient, and is responsible for documentation of billable time and medical necessity. This is the foundation for the creation of the claim, and reimbursements.

As clinicians, we provided skilled services, and the proof of those skilled services is clinical documentation. So we want to treat patients but need to document.

This disconnect between the ‘want’ and the ‘need’ creates a fear.

The fear is “What if I don’t document correctly?”.

This creates a vicious cycle where we document too much. Fear makes us focus on quantity as opposed to quality of documentation.

On the other hand, access to the right physical therapy documentation examples can help us focus on quality, as opposed to quantity of documentation.

As clinicians, we want to focus 100% of our energy on the patient, but instead we find ourselves transformed into data entry machines and glorified typists, of the need to document too much which creates an irrational fear or denials.

Whether we like it or not, we have to document, and clinical documentation of skilled services can be time consuming. That’s why this article on 10 ways to speed up physical therapy documentation should help.

To make your life easier, we have taken the time to analyze various documentation systems. We have also taken the time to compare medical billing software and created a comprehensive resource for you. It is a summary of all the physical therapy forms you need in your practice. We also provide you with an option to download done-for-you templates for documentation.

Documentation – Intake Paperwork Before the Visit

Documentation begins even before the patient is seen by the clinician.

With most healthcare practices, there are forms that need to be completed by the patient prior to the initial examination by the therapist.

The medical history form or the initial patient intake form establishes a foundation for identifying and treating the patients problems.

By signing the consent form, the patient gives written permission to the clinic to explore payer eligibility, communicate with other healthcare providers about the patients condition, examine the patients and act on behalf of the patient to provide necessary care.

For your convenience, we are, for a limited time, allowing you to download the In Touch EMR physical therapy documentation examples set. This set includes the following:

Download the In Touch EMR Intake Paperwork Templates Set

physical therapy documentation examples, physical therapy forms, physical therapy documentation samplesThis download includes:

  • Authorization and Consent to Treat a Minor
  • Consent for Care
  • Patient Intake Form (editable)
  • Patient Medical History
  • Patient Information Release Policy
  • New Patient Registration Form

Click the button below to get this entire form set delivered to you by email.


Defensible Documentation – Proving Medical Necessity for Skilled Services During the Visit

Physical therapy documentation should justify medical necessity.

physical therapy documentation examples, physical therapy forms, physical therapy documentation samplesThe rendering provider (clinician) has the unique skills, expertise, knowledge, experience and clinical judgment to provide a set of skilled services to the client or patient.

Physical therapy forms should address several important questions to establish medical necessity.

For starters, will this result in an improvement in the patient’s condition?

It is imperative to document justification for services rendered, and not just bill services, but document why you billed what you billed (this is the basis of the design of the flowsheet component in In Touch EMR).

Ask yourself – Are you doing this consistently?

The treatments that are provided – are they absolutely necessary?

If they are, are the skills of a licensed therapist needed?

Physical therapy documentation should explain what the patient is doing, and what it is that the provider is doing / the manner in which the provider is contributing to make the treatment process billable as ‘skilled care’ that is ‘medically necessary’.

Once the treatment has begun, the therapist must monitor the treatment regularly. The rationale for clinical decisions must be documented at regular intervals.

This is achieved with a combination of customized physical therapy documentation examples, specific to the patient and your treatment philosophy, regular tests, standardized tools, subjective feedback and various measures.

When the clinician combines clinical judgment with subjective findings reported by the patient and caregiver considerations, a precise clinical picture emerges.

The clinician is now able to identify where the patient was, where the patient needs to be, how soon they need to get there and most importantly what needs to be done to get there. This is called the ‘clinical gap’.

The ‘clinical gap’ between where the patient is right now, and where they need to be, is used to create short term and long-term goals.

Outlining patient progression through a series of goals that are achieved and modified is an excellent way to convey progress and justify treatment.

The end point of therapy also needs to be clearly defined. The moment the patient can:

a) Complete exercises / treatment safely and effectively on their own and
b) Work with a caregiver to achieve outcomes

…At that point, skilled therapy may no longer be necessary.

If and when you fall under the scrutiny of an auditor, the auditor will essentially ask:

“Why did the patient come and see you? Provide some details about the onset of injury.”
“What is the patient’s point of view? Show me the subjective intake of the initial evaluation.”
“What is the illness? What was the mechanism of the injury?”
“Was skilled therapy needed? Did it result in an improvement in the condition of the patient and help the patient get back to activities of daily living?”

Here are some additional guidelines for defensible documentation:

  • Documentation is required for every visit/encounter.
  • All documentation must comply with the applicable jurisdictional/regulatory requirements.
  • All handwritten entries shall be made in ink and will include original signatures.
  • Electronic entries are made with appropriate security and confidentiality provisions.
  • Charting errors should be corrected by drawing a single line through the error and initialing and dating the chart or through the appropriate mechanism for electronic documentation that clearly indicates that a change was made without deletion of the original record.
  • All documentation must include adequate identification of the patient/client and the   physical therapist or physical therapy assistant:
  • Documentation should include the referral mechanism by which physical therapy services are initiated.
  • Documentation should include indication of no shows and cancellations.

Download the In Touch EMR Physical Therapy Documentation Examples Set

physical therapy documentation examples, physical therapy forms, physical therapy documentation samplesThis download includes a complete outline of the required data points for all document types, including initial evaluation, reevaluation, progress note, daily note and discharge note. Here are just some of the data points included in the download file.

  • Documentation of history may include demographics, social history, employment/work, general health status and more..
  • Documentation of systems review may include cardiovascular/pulmonary, integumentary, musculoskeletal, neuromuscular and more..
  • Documentation of systems review may also address communication ability, affect, cognition, language, and learning style.
  • Documentation of tests and measures may include findings for
    aerobic capacity/endurance, anthropometric characteristics, arousal, attention, and cognition
  • Assistive and adaptive devices and equipment use during functional activities
  • Environmental, home, and work (job / school / play) barriers
  • Ergonomics and body mechanics
  • Gait, locomotion, and balance
  • Assessment of pain and posture
  • Assessment of joint active and passive movement, muscle strength and more
  • Self-care and home management (including activities of daily living and instrumental activities of daily living)
  • Documentation of the plan of care including goals stated in measurable terms that indicate the predicted level of improvement in functioning, a general statement of interventions to be used, proposed duration and frequency of service required to reach the goals and anticipated discharge plans

Click the button below to get this entire form set delivered to you by email.

Need More Information about In Touch EMR? Contact Us

In Touch EMR is a fully integrated scheduling, documentation and billing software for physical therapy practices. It is a simple and user friendly web-based, ICD-10 and HIPAA compliant EMR, and it offers customizable templates for notes, the ability to attach files, electronic signatures, and the ability to track progress notes, treatment plans, and assessments.

Please click here for a brochure of In Touch EMR. (please right click and choose ‘save as’ to download the brochure).

Click here for answers to your most frequently asked questions about EMR selection and transition.

In Touch EMR has grown to over 1000 clients, our company / founders have been mentioned on CNN, Forbes, Huffington Post, Amazon, been featured as a Cleardata success story, received the prestigious ONC certification, 2015 and 2016 PQRS registry designation, integrated with Microsoft’s cutting edge patient portal technology and initiated groundbreaking healthcare partnerships with companies like Novartis. All of this is possible thanks to clients across the country, who have embraced In Touch EMR.

In Touch EMR is featured on our HIPAA compliant hosting partner (Cleardata) website along with other industry leaders such as the Cleveland clinic, Nexttech, Saint Mary’s regional medical center and UCLA health.


At In Touch EMR, we charge a flat fee per licensed clinician (no hidden fees or surprises) and it includes everything, unlimited claims and notes and infinite custom template creation. We are also a CMS recognized PQRS registry, we automate the reporting of PQRS and Functional Limitation G codes and provide automatic alerts for plan of care expirations, authorizations, progress note reminders and KX modifier alerts.

Clients also get a self-paced video training program on how to get up and running, custom documentation template builder, iPad app – one touch document import, Instant Intake iPad app, unlimited patient manager and patient portal.

Every license unlimited ongoing support (phone / email / live chat), billing software integration, unlimited appointments, unlimited documentation, unlimited document uploads and unlimited electronic faxing.


We are a premier vendor in the rehabilitation space, and on the prestigious, certified Health IT Product List, which is a division of the office of the National Coordinator for Health Information Technology, a division of the Department of Health and Human Services.

Very few vendors can make this claim, and they generally won’t bring this up (in some cases, out of ignorance) mostly because this is not a mandatory certification, it is optional and requires a significant investment of time and effort. This certification is a sign of our commitment to a HIPAA compliant, secure and stable EMR system for your clinic.

If you ever get audited, the fact that you are using ONC-certified EHR technology (CEHRT) will work in your favor. CMS looks favorably on the use of CEHRT since HHS is trying to encourage the adoption of CEHRT amongs providers nationwide as part of a long term push towards electronic documentation and interoperability between EMR systems. Your practice can state that it carefully vetted and selected “a rehabilitation-specific vendor that passed  all of the ONC HIT 2014 Edition EHR Certification criteria required to satisfy the Base EHR definition”

Since In Touch EMR has been very proactive at staying at the forefront of emerging guidelines for EMR vendors, you are assured higher quality, higher security and more compliance with CMS and other payer regulations.

For more information about the ONC, please visit:

In Touch EMR is one of the only EMR vendors in the rehabilitation space to pass all the 2014 Edition EHR Certification criteria required to satisfy the Base EHR Definition as stated by the Office of the National Coordinator for Health Information Technology, as listed here:

In Touch EMR is on the Certified Health IT Product List (CHPL) website.

The product is listed here:

Search for In Touch EMR > CHPL Product Number: 150002R00


“In Touch EMR has emerged as a comprehensive, customizable EMR solution for our growing organization. Support is always there when we need it, options to customize options to match our workflow are endless, clinicians find it simple and easy to use, front desk and billing love the integration between documentation and claims and compliance is built-in. This is exactly what we needed and it has boosted our efficiency. Couldn’t have asked for more. In Touch EMR is a leader in web-based EMR for our practice. Thank you!”

Julie Edelman PT, DPT – Avanti Therapy

“Moving to In Touch EMR was a process of adjustment, but it was worth it, for several reasons. Not only has the staff at In Touch EMR been proactive in adding new features and responding to support calls and streamlining our billing processes, they have been understanding, professional, polite and patient. The ability to create our own documentation templates, generate professional reports on demand and submit claims to billing with one click has allowed us to streamline our practice. The billing software is extremely versatile – I can review number of claims sent / on hold, payer breakdown, charges per visit and collections per visit. Our biller is able to pull up detailed reports, exactly the way we want. My front desk staff has the ability to track authorizations and create progress note alerts, physician prescription alerts and fax reports to physicians with the click of a button in In Touch EMR. My management is now exploring analytics to identify areas of growth and efficiency and expect to drive our practice further with analytic insights. Best of all, the transition for our entire staff was streamlined and consistent and help was readily available. I like that we are able to talk to someone whenever we need to. If you are looking for a powerful, reliable, and responsive team to help you implement EMR and billing software to grow your practice, look no further than the team at In Touch EMR. We support this therapist owned EMR company wholeheartedly.”

Matthew S. Fischer, MSPT – Fischer Physical Therapy

“In my 30+ years as a compliance auditor, author and instructor, I have yet to see an EMR and billing software as comprehensive as In Touch EMR. If you are looking for compliant ICD-10 documentation, and a ‘gold standard’ that can survive auditing, get In Touch EMR. A well defined workflow for the front desk, clinicians, billers and coders makes this a one-stop shop for quick, compliant documentation and flawless billing. I’m impressed with their HIPAA compliance, PHI protection and data breach prevention protocols. The front desk automation (certification alerts, patient portal, birthday reminders, e-newsletters) and clinician automation (progress note and reevaluation countdown, autotext technology, flowsheet templates, tasks and messages) are sufficient to set them apart. They didn’t stop there. The billing automation (claim cleanser, automatic transmission to billing, CCI edits – modifier 59 automation, autopost ERAs) and the administrator functions (access controls, audit logs, time tracking, productivity metrics) result in an incredible EMR and billing software combination for all clinicians. It’s a no brainer – forget the hype from other products and get In Touch EMR”

Cheryl House RMC, CHI  Compliance Auditor, Author, Coder and Instructor at Illinois Valley Community College

“I was looking for a Practice Management Software that combined both documentation and billing platform systems that work in unison. I had previously tried more complicated systems that made me exhausted at the end of the day. In Touch EMR and In Touch Biller Pro represent a united and unified package that helps the private practice clinician govern a practice. It’s easy to use, it is concise, and it has a plenty of analysis variables to study.”

Sammy K. Bonfim PT – Rehabilitation & Performance Center

All In Touch EMR customers get unlimited support via phone, email and live chat.

Click below to schedule a free demo with the experts at In Touch EMR, or call (800)-421-8442 to learn more.

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At In Touch EMR, we charge a flat fee per licensed clinician (no hidden fees or surprises) and it includes everything, unlimited claims and notes and infinite custom template creation. We are also a CMS recognized PQRS registry, we automate the reporting of PQRS and Functional Limitation G codes and provide automatic alerts for plan of care expirations, authorizations, progress note reminders and KX modifier alerts. Schedule a demo to see why practices across the country are switching to In Touch EMR.