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Physical Therapy Goal Documentation

Physical therapy (PT) can be used to treat a variety of conditions, from broken limbs to neurological disorders like cerebral palsy and Parkinson’s disease. A doctor will prescribe PT when she feels the patient would benefit. Physical therapy goal setting is typically done in a therapist’s initial session with a patient through PT documentation. Physical therapy documentation is the record a physical therapist keeps for each patient. Notes from the initial session and the records of each follow-up session are amongst the information recorded in PT documentation.

  1. Physical Therapy Goal Setting

    • When a doctor prescribes physical therapy, he should also recommend a resource from which the patient can receive the physical therapy. Children with disabilities often have access to physical therapists through the public school system. Other places physical therapy is offered include hospitals and rehabilitation centers.

      In the initial session, often called the examination, the therapist will analyze the patient’s medical history and physical capabilities. Gait (manner in which the patient walks), balance and limb mobility are among the physical elements the therapist will take note of for PT documentation. By analyzing the patient’s medical history and physical capabilities the therapist will be able to determine the patient’s limitations. Knowing the limitations of the patient is important for physical therapy goal setting. Keeping the patient’s limitations in mind, the therapist and patient can work together to draw up reasonable and reachable goals.

    Follow-up

    • The initial examination portion of physical therapy documentation gives a general outline on how the therapist and patient will achieve the patient’s goals. As a part of PT documentation the therapist records the progress the patient is making from session to session. In this portion of the PT documentation the therapist gives a detailed account of how the therapist and patient will work to achieve the goals set. Information included in this portion of the documentation may include progress with exercises and changes in physical therapy routines.

      When a patient achieves her goals, new goals should be set. This should be done every time the patient reaches her goals. The continuous routine of physical therapy goal setting is especially important for patients who have long-term disabilities.

    Discharge Report

    • For patients who have temporary conditions, physical therapy is discontinued once the therapy is no longer beneficial. For example, a person who breaks his leg will discontinue with physical therapy once he is fully recovered from the injury. The therapist fills out a discharge report to close out the physical therapy documentation paperwork. The discharge reports acts as a summary of the physical therapy sessions and indicates any precautions the patient should take in the future.

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