1. By Dr. Ali Abd El-Monsif Thabet

2.  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.

3.  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

4. Signed Consent Patient Identification Information Start of Care Date

5. Medical Diagnosis Physical Therapy Diagnosis:

6. Medical History Related Medical Testing Results

7. Patient/Family/Therapy Goals Prior Functional Level

8. Social History/support Precautions/contraindicati ons/Barriers

9. Baseline Data from Tests and Measures

10. Architectural/Safety Consideration

11. Problem Summary

12. Plan of Care

13. Authentication

14.  Physician's Certification and Recertification

15.  Coding and Documentation

16.  Principles of Code Use

17. Non-Covered Conditions and Services

18. Thank you