Tips For Creating Physical Therapy Progress Notes

Progress notes are required by many healthcare practitioners, including physical therapists. They focus on specific details from each session with a patient, including diagnosis, prognosis, and target objectives.

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Understanding progress notes

Understanding progress notes

Progress notes are a form of clinical documentation required by many healthcare practitioners, including physical therapists. They focus on specific details from each session with a patient, including diagnosis, prognosis, and target objectives. Progress notes are beneficial from a practitioner's perspective. They allow them to track the success of their interventions and treatments and are valid reference documents for clients who experience similar issues. 

Further, progress notes are legal documents that can be shared between other healthcare providers, insurance workers, and lawyers to ensure that a client has received the best quality of care possible. It is in the best interest of all physical therapists to write accurate and effective progress notes to ensure quality healthcare and prevent any harm affecting either the patient or the practitioner.

What is a progress note for physical therapy?

Physical therapists, just like many other practitioners, are required to maintain clinical documentation. The exact information contained in clinical notes by physical therapists will depend on the nature of the injury being treated and how far along into the client's rehabilitation process. Generally, physical therapy progress notes should determine the client's current status concerning their target goal. The progress note should describe the intervention process and its success, resolving any potential changes or modifications to the treatment plan.

How do you write a progress note for physical therapy?

Although necessary, medicare documentation requirements can seem complex and overwhelming for physical therapists. To ensure that your progress notes meet all the essential criteria, we have summarized the various elements identified by Medicare that physical therapists need to keep in mind when documenting their sessions. Including this information within your progress note will ensure you meet the criteria for claims and avoid any problems regarding malpractice suits.

Physical therapy progress note requirements

  • The Time Frame
  • Patient Subjective 
  • Objective Measures
  • Statement on Improvements 
  • Changes to Goals
  • Plans for Continuation
  • Signature and Date
How do you write a progress note for physical therapy?
Tips for creating practical PT progress notes

Tips for creating practical PT progress notes

Creating practical physical therapy progress notes has a crucial role in ensuring patients receive the best quality of care possible and protecting the therapist against malpractice or other lawsuits. Here are some strategies that will help streamline this process and lead to the best possible physical therapy progress notes!

  • Relevance: You don't have to include every aspect of a session within your progress note. Make sure you only reference the specific activities and measurements that directly relate to your client's progress.
  • Include Comparisons: Documenting a client's progress can be assisted by comparing their results on tests during the current session with a previous session. This is a simple way to demonstrate whether your treatment plan works for other physicians and healthcare providers.
  • Updates: Include specific comments on the improvement, or lack of progress, noted in your client. You must provide evidence, such as assessment results, to support these comments.
  • Future Plan: The progress note should be concluded with a detailed and specific plan relating to the client's target objectives. It would be best to outline whether the treatment plan requires any modifications and determine both short-term and long-term goals.
  • Legibility: Although it may seem obvious, don't underestimate the importance of legibility. If your progress notes are not legible, some insurance companies will deny payment. We recommend using online clinical documentation software so you can eliminate one extra worry!
  • Reporting Period: All of your clinical documentation must be written within the reporting period of 10 treatment visits or 30 days.

Physical therapy progress notes example + template

Different formatting guidelines have been developed to help with writing progress notes, including SOAP and DAP. Depending on your preferences, and the requirements of your practice, you may choose to utilize physical therapy software to help streamline your clinical documentation. Remember, consistency is key!

Physical therapy progress note example

This template is indicative of the type of information that physical therapists should include in a SOAP note. We will break down the different sections and provide you with a brief example of what should be included.

  • Subjective (S): Subjective statements from the patient about their feelings and any progression they have noticed since the beginning of treatment. 

The patient says that over the past week, the pain in her shoulder has been 4/10. She says she can now move her arm to head-level without experiencing sharp pain in her shoulder. She has been using muscle relaxants.

  • Objective (O): This section includes the results of any relevant tests and assessments completed during the session. It would help if you discussed whether the results of these tests are positive or negative. 

The patient's PROM for flexion has improved from 90 degrees to 140 degrees. The strength in her available range of motion has been enhanced from 3+/5 to 4+/5.

  • Assessment (A): A professional conclusion based on information provided in the subjective and objective sections. Comment on the patient's progression towards their goals and whether you recommend any changes or modifications to the treatment plan. 

The patient has achieved their short-term goals as identified in the last session. Long-term goals, including full ROM into shoulder flexion, have not yet been reached. We will target these objectives during the subsequent four sessions.

  • Plan (P): The final section of a SOAP note outlines the specific treatment plan and intervention for the patient, including future assessments, referrals, and sessions. 

The patient has demonstrated improvements, so that we will continue the current treatment plan. The patient will have a PT session weekly over the next four weeks.

Final thoughts

Learning how to write practical progress notes is a critical aspect of providing quality healthcare to your clients. There are different strategies for physical therapists that can assist in producing clinical documentation, including using a SOAP format and online therapy software. Carepatron offers HIPAA-compliant sophisticated, and high-quality services that can help you in the process of writing efficient and effective physical therapy progress notes. 

Hopefully, this guideline has given you insight into the different methods and techniques that can be utilized to write accurate progress notes. As long as you keep on top of your documentation and prioritize consistency, clarity, and conciseness, your progress notes will work to both your and your patient's advantage!

Further Reading

Physical therapy progress notes example + template

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