By Dr. Ali Abd El-Monsif Thabet

 There are basic requirement for all PT services: (1) Physician order, (2) Evaluation, (3) Plan of care, (4) Ongoing documentation of care, (5) Re-evaluation, and (6) Discharge summery.

 It is preferable to include as much information as possible in the record at the initial visit.  Content of the initial visit documentation: Referral Information

Signed Consent Patient Identification Information Start of Care Date

Medical Diagnosis Physical Therapy Diagnosis:

Medical History Related Medical Testing Results

Patient/Family/Therapy Goals Prior Functional Level

Social History/support Precautions/contraindicati ons/Barriers

Baseline Data from Tests and Measures

Architectural/Safety Consideration

Problem Summary

Plan of Care

Authentication

 Physician's Certification and Recertification

 Coding and Documentation

 Principles of Code Use

Non-Covered Conditions and Services

Thank you