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. OT graded the task based on patients response to exercise. See privacy policy and disclosure page for details. Patient denied pain, just complained of overall weakness. Patient reported functional progress with opening jars in prep for feeding and grooming tasks. Knowing appropriate Physical Therapy documentation phrases can help explain your intended treatment and justify more complex treatments such as neuromuscular re-education, therapeutic activity, and self-care. 1. An occupation requiring knowledge or skill. SUPINE EXS QUAD AND GLUT SETS X 10; HEEL SLIDES, SAQ, IR/ER, PASSIVE HIP ABD AND ACTIVE HIP ADD, LAQ X 10 WITH L LE; STANDING TOE RISES, MARCHING IN PLACE, HIP EXT AND HAMSTRING CURLS X 10 WHILE HOLDING ONTO WALKER FOR SUPPORT. 26 N. Beach St., Suite A 2021 PTProgress - Our content does not constitute medical, financial, or legal consultation. Assessed The medical history form or the initial patient intake form establishes a foundation for identifying and treating the patients problems. You may also document treatment provided in a flow sheet. In any case, the intensity of therapy shall be reasonable and necessary and shall never exceed the patient's level of need or tolerance, or compromise the patient's safety. Provide some details about the onset of injury. Patient arrived at therapy 6 weeks post R humeral fracture. Is a qualified nurse or therapist needed to provide or supervise a level of care? 13. Verbal cues were provided to improve postural alignment and engage in pursed lipped breathing to maximize functional tolerance. We have also taken the time tocompare medical billing softwareand created a comprehensive resource for you. 1. All products are digital and delivered immediately. Pursuant to Jimmo, medically necessary nursing and therapy services, provided by or under the supervision of skilled personnel, are coverable by Medicare if the services are needed to maintain the individuals condition, or prevent or slow their decline (To learn more about the Jimmo Settlement, click here). Patient lacks full strength to ascend full flight of stairs reciprocally and demonstrates impaired balance on dynamic surfaces. Email:Help@HomeCEU.com DO NOT assume Medicare is unavailable based on: Rules of Thumb, Diagnosis, Wants or Needs. 10 minutes Manual Therapy (97140): Seated tibiofemoral distraction grade 2 mobilization for pain relief, supine patellar mobilizations in superior/inferior direction: grade 2 x 4 minutes, mobilization with movement of patella with SAQ x 3 minutes. Within 2 weeks, the patient will report a 20% reduction in knee pain at night in order to facilitate their ability to fall asleep. Develop maintenance programto be carried out by patient and caregiverto ensure optimal performance of trained skills and/or to generalize use of skills. Recommend continue POC. Posture: Patient stands with forward flexed trunk position using walker and demonstrates a favoring of the left knee in keeping it flexed. trained in ankle dorsiflexion, plantar flexion, inversion/eversion with 3 second hold. American Physical Therapy Association (APTA)). Documentation is required at the onset of each episode of physical therapy care and Documentation must support the need for Skilled Maintenance and clearly show a reviewer why the service could not be . Below is an example of documentation that is not best practice in support of a patient who is not clinically appropriate for group therapy, and an auditor's comment regarding the documentation. Patient is at risk for increased back pain without training to stabilize core muscles. Patient instructed in glute squeeze, Kegels, hip abd, hip add with pelvic floor activation holding 5 seconds each 310. Patient arrived at therapy with 3/10 L hip pain. Use of this and other APTA websites constitutes acceptance of our Terms & Conditions. A skilled PT is required to address these key impairments and to provide and progress with an appropriate home exercise program. Patient instructed in single leg raise AROM with max vc and tactile cues to focus on quad contraction, quad sets (3 sec muscle contraction with max vc and tactile cues, heel slides with 3 sec hold in flexed position, hip abd with knee ext 2# with cues to maintain hip in neutral and overall correction of technique. `T81:^acePnaTcskG?IF\@\R XAaH200 ~# endstream endobj 200 0 obj <>/Metadata 10 0 R/Pages 197 0 R/StructTreeRoot 28 0 R/Type/Catalog>> endobj 201 0 obj <>/MediaBox[0 0 612 792]/Parent 197 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 202 0 obj <>stream 17. Privacy Policy | Website Supported by Paradox Marketing, Harmony Healthcare International (HHI) Blog, Maintenance Therapy: Skilled Nursing Facility Goal Setting, 2023 Harmony Healthcare International, Inc. (HHI). The patient demonstrates lack of quad muscle recruitment during knee extension. Standing: mini squats x 10, hip abduction x 10 bilaterally, hamstring curls x 15 bilaterally, step up to 3 step x 10 alternating LE. Patient will be seen by a PT and/or PTA 2x per week for 6 weeks under the diagnosis of Left knee OA s/p L TKA and will be reassessed every 7-10 visits for progress. The patient has achieved 100% of short-term and long-term goals. What are the skilled areas that require maintenance therapy? All contents 2023 American Physical Therapy Association. Group therapy documentation must demonstrate that group therapy is medically necessary and appropriate. 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. : educated pt for at home safety w/ emphasis on _________to improve (I) and return to PLOF. Ormond Beach, FL 32174 Reinforced proper posture and provided cues for safe lifting of items overhead throughout treatment., Provided verbal cues to correct for anterior translation of femur with squatting and to promote the appropriate body mechanics for sit- to- stand transfers and other functional activities., Instructed performance of squatting with a weighted object in order to improve sit-to-stand function. For Part A settings: Physical therapist assistants under the supervision of the PT are permitted to perform both rehabilitative and maintenance therapy services under a maintenance program established by a qualified therapist under the Medicare Part A home health or SNF benefit, if acting within the therapy scope of practice defined by state licensure laws. In March of 2016 the Center for Medicare Advocacy went to court to enforce the ruling of the Jimmo settlement and they reiterated the inadequacy of the Educational Campaign that the Center for Medicare and Medicaid services were mandated to provide. The patient will identify potential fall hazards in path with potential loss of balance 80% accuracy through daily skilled intervention with physical therapy. Assessment Statement: Patient presents with signs and symptoms consistent with diagnosis of L knee OA, s/p 1 week post operative L TKA. No signs of infection noted. Documentation should include the referral mechanism by which physical therapy services are initiated. PTM has one of the largest databases of outpatient PT/OT provider productivity, visit and payment information, with more than 5 million visits. See more onMedicare payment for home health. Patient educated and instructed in R hip exercises to increase R hip ROM/strength for improved balance, pain reduction, as well as core strengthening to reduce compensatory strategies for improved posture. Modified It is not necessary to establish rehabilitation or restorative therapy prior to the maintenance program, as long as the documentation justifies the need for skilled therapy to maintain function, or prevent or slow deterioration. 0 2023 Harmony Healthcare International, Inc.. All Rights Reserved. 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. This disconnect between the want and the need creates afear. Hint 2: When you write the subjective section, you need to be as concise as possible. For more information about the ONC, please visit:http://www.healthit.gov/newsroom/about-onc. These Therapy Documentation Templates will help you effortlessly write physical therapy assessment phrases that are as skilled as the treatments you provide in the clinic. (Skilled terminology is highlighted in red.) RR <20 following task and RPE 2. Patient arrived at OT for engagement in incontinence management including PMEs to reduce urinary urgency. Documentation Concepts Rehab -Maintenance Assessments Rehabilitative Maintenance Documentation is required for every visit/encounter. hbbd``b`$V w`" D 8AD,`T\Q@P#S(Fb 0 ( My management is now exploring analytics to identify areas of growth and efficiency and expect to drive our practice further with analytic insights. 15. Patient instructed in RLE exercises to increase LE strength s/p R knee replacement. By end of session, patient stated, I have noticed I am able to hold it in longer.. The documentation of the visit should alwaysdemonstrate that the treatment provided required the skilled services of the therapist and could not have been safely and effectively accomplished by the patient, family, caregiver or unskilled personnel. 4 0 obj If you didnt provide any cueing, recommendation, or therapeutic insight or intervention, what did you do?? I can walk for about 20 minutes with the cane before I need to sit to rest., Attendance: Number of Treatments: 7; Cancellations: 0; No Shows: 0, Treatment Included: Ther ex, neuromuscular re-ed, manual therapy, cold pack, HEP. Physical Therapy Documentation Examples and Documentation Best Practices Physical Therapy Documentation Examples (Downloadable) and Best Practices with Physical Therapy Forms At In Touch EMR, we get daily calls from clinicians, owners and students asking us for physical therapy documentation examples that qualify as 'defensible documentation'. Are you a business looking to collaborate? Patient reports decreased sensation along the incision line; sensation is intact otherwise. With our comprehensive collection of high-quality examples, you'll be able to improve your documentation skills and increase productivity. . OT developed HEP and patient instructed in self ROM/stretches to increase I with HEP for BUE exercises. Each is allowable and reimbursable by Medicare. Once the treatment has begun, the therapist must monitor the treatment regularly. 18. All documentation must comply with the applicable jurisdictional/regulatory requirements. Couldnt have asked for more. Prior Functional Level: Patient was independent in all areas. Follow him on YouTube for weekly videos on ways to improve your financial health. hb``` ,|qcb N%DX44KK W?58[zD=h0h`@F@ 4e'i^ [`B+3]1`|Gy 'C*H3* -H30.{HQYJ :9Y Phone:1800.55.4CEUS (2387)Privacy Policy. The Physical Therapy (PT) daily note read: "AAROMEs of B LE x 20reps x 3 sets to improve strength and mobility of B LE. Physical Therapy Documentation: Why Intent Matter. In Touch EMR has grown to over 1000 clients, our company / founders have been mentioned on CNN, Forbes, Huffington Post, Amazon, received the prestigious ONC certification, 2015 and 2016 PQRS registry designation, integrated with Microsofts cutting edge patient portal technology and initiated groundbreaking healthcare partnerships with companies like Novartis. Words and phrases that therapists and assistants should avoid because they often demonstrate lack of skilled care include: Tolerated well Patient denied shortness of breath and indicated just right challenge. In addition to supervising the services provided by the PTA, the qualified therapist is still responsible for the initial assessment, plan of care, maintenance program development and modifications, and reassessment every 30 days. Please read my disclosure for more info. Monitored Long-term goals will be addressed with further treatment. This means that your documentation should: Explain your reasons for choosing group therapy, including in each patient's plan of care explicit justification for choosing group therapy as an adjunct to individual or concurrent therapy. _[a@>Ak*-'*571?SpnpfC6B@"FVYx7Bl)$[E_}md_`x2Xs8Yy These dynamic activities must be part of an active written plan of care and be directed at a specific outcome. It also means keeping record of your sessions and of your client's progress note, or lack thereof. If they are, are the skills of a licensed therapist needed? Patient with max cues for posture to reduce trunk sway with standing tasks. Without PT, patient is at risk for further decline as patient lives alone and was I with all tasks. O2 > 96% when monitored during rest breaks, RR 22 post exercise, 18 at baseline. The conscious use of skill especially in the production of works. On the other hand, access to the right physical therapy documentation examples can help us focus on quality, as opposed to quantity of documentation. abMbout Maintenance Therapy Diana Kornetti, PT,MA Cindy Krafft, PT, MS . Patient instructed in BLE recumbent bike training to increase overall functional activity tolerance and LE strength to maximize balance and reduction of falls during mobility. 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. Documentation begins even before the patient is seen by the clinician. o Degree of goals achieved and reasons for goals not being achieved. Task adapted and modified in response to patients complaints, however, patient with increased pain to 8/10 with stretching. Inhibit It can also be the cause of major headaches, rushed lunch hours, and excessive typing throughout the day. Jimmo, Data collection is the foundation for monitoring progress, but, in itself is a daunting task. For your convenience, we are, for a limited time, allowing you to download the In Touch EMR physical therapy documentation examples set. If theres one area of training that could improve in Physical Therapy school, it would be learning how to document therapy sessions effectively. PHd$2 +4^{D=fO:%hWVuOq~4ssatP6 Further progress will involve the removal of hand-hold assist., The patient lacks balance and stability required to stand on a single leg. Patient stated, wow Im really out of shape, but with education on energy conservation techniques, was able to complete the task. By using this site, you are consenting to our use of cookies. Patient instructed in GE towel slides flexion/extension and horiz add/abd on table top 310 with assistance of LUE as needed; however, OT facilitated constraint therapy to increase RUE movement. With most healthcare practices, there are forms that need to be completed by the patient prior to the initial examination by the therapist. PT facilitated patient to complete standing ther ex including heel raises with BUE support, using mirror for visual feedback to ensure proper form, 215. Driving under the influence of drugs or alcohol. Treatment Provided: Total knee protocol to include instruction of HEP and performance of the following exercises: ankle pumps x 20, quad sets x 15, SLR x 10, sidelying SLR x 10, glute squeezes x 20, mini squats x 10, heel slides x 15. In Touch EMR is on the Certified Health IT Product List (CHPL) website. These sample phrases may be used in the objective (observational) or assessment (interpretation and judgment) sections of your therapy documentation. Medicare, Then put whatever you mentioned for education. Patient also instructed in pursed lipped breathing to reduce complaints of shortness of breath and elicit usage of energy conservation techniques. Verbal/visual/tactile cues for increased recall, problem solving, sequencing or overall technique. <> OT individualized and instructed patient in AROM exercises to max patient range in pain free zone as follows: IR/ER, abd/add 110, extension with 3 second hold. Will require further skilled services to increase weakened RLE. At In Touch EMR, we get daily calls from clinicians, owners and students asking us for physical therapy documentation examples that qualify as defensible documentation. Treatment included conversational practice. It forces us to document. The treatments that are provided are they absolutely necessary? Click here for answers to your most frequently asked questions about EMR selection and transition. Within 4 weeks, the patient will demonstrate independent ambulation on level surfaces without a straight cane in order to safely navigate the community without gait compensation. Patient frustrated at times, but OT provided hand over hand as needed and patient with resultant improved performance. 20 minutes Therapeutic Exercise (97110): Supine exercises included: active quad sets x 15, SLR x 15, Hamstring curl x 10 with ankle dorsiflexion x 3 each rep, SAQ with bolster x 15. Use Shortcuts to Save Time. Im impressed with their HIPAA compliance, PHI protection and data breach prevention protocols. Physical therapy forms should address several important questions to establish medical necessity. Physical therapy documentation templates are simply a predetermined structure designed to reduce errors, increase efficiency, and improve job satisfaction. Discharge from PT x Continue PT 2 x per week for 3 weeks. Patient arrives to therapy with complaints of sciatica. During Harmony Healthcare Internationals (HHI) LTPAC Interdisciplinary Symposium, harmony16, guest speaker, Ali Bers, Attorney with Center for Medicare Advocacy shared her knowledge and passion for supporting ongoing skilled services to our elder population. Patient completed x 15 minutes with PT facilitating interval training of varying resistance 1-2 minutes. Every license unlimited ongoing support (phone / email / live chat), billing software integration, unlimited appointments, unlimited documentation, unlimited document uploads and unlimited electronic faxing. Patient now cleared to begin ROM exercises per MD documentation. In Touch EMR is a leader in web-based EMR for our practice. 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. The exercises that are performed will depend on each patient's unique conditions, but might include: Swimming Walking Aerobics Jogging Cycling Rowing Squatting Stretching Stretching helps to maintain flexibility and mobility. Required max verbal cues, tactile cues and visual demo to reduce compensatory strategies. Basically,you want to show the reviewer that you are using your professional skills to teach/train the patient and the caregivers/staff,with your skills,which no one else could teach. Send us a note. 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. Patient arrived at PT with 4/10 R hip pain. Max vc to execute properly. Patient instructed in 5 minutes of level 1 resistance then graded to level 2 resistance for 5 minutes and finally level 3 resistance for the remainder of task. endobj This set includes the following: Physical therapy documentation should justify medical necessity. It is a summary of all the physical therapy forms you need in your practice. A template might be as simple as an outline to help guide a clinician's initial evaluation or it might be as complex as a complete evaluation with blanks left for new information. Patient was able to execute with no increase in pain in prep for gait training. If you ever get audited, the fact that you are using ONC-certified EHR technology (CEHRT) will work in your favor. <> The patient will maintain the use of safe swallow strategies as instructed by Speech therapy at each meal to prevent aspiration. Our biller is able to pull up detailed reports, exactly the way we want. Click below to schedule a free demo with the experts at In Touch EMR, or call (800)-421-8442 to learn more. Thanks The therapist can personally provide ongoing skilled maintenance therapy due to safety and/or complexity of your situation. 443-850- 0421, Pt continues to disregard side rails (whatever theyre being non compliant with, cane, crutches etc. 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. Auditors often rely on repetitive or otherwise poor documentation to deny a claim based on the conclusion that therapeutic exercise did not require the skills of a therapist. Did it result in an improvement in the condition of the patient and help the patient get back to activities of daily living?. A physical furthermore occupational therapist providing you at evidence-based treatments both samples starting record into show your skill. The end point of therapy also needs to be clearly defined. The patient reports having knee pain for years before he consulted with an ortho surgeon in August of 2015. to develop a key of frequently used abbreviations on most documentation forms or request therapists to completely spell any word the first time it is written with the shortened form in parentheses (e.g. Save my name, email, and website in this browser for the next time I comment. Do you have occupational therapy templates? In seated position, patient was instructed in LLE strengthening exercises to decrease left foot drop during ambulation prior to functional mobility task. Q Can you please give some examples of documentation that shows the unique skill of a therapist in a maintenance scenario? See privacy policy and disclosure page for details. Instructed patient in co-contraction of quads to improve motor recruitment in order to achieve greater knee extension. Reduced Across PT sub-disciplines, there are different standards for official physical therapy documentation. Individualized 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. Instructed I am a physical therapist in the homecare setting. I - Identify OT as an essential partner in client's therapy plan. Rather than singular phrases, document the billing code, the body part (s) treated, the muscles and joints targeted, and the specific activities performed, such as isometric or isokinetic exercises. Integumentary: Surgical incision noted along midline of left knee. T - Thoughtfully share challenges and how OT can help push through. As best practice, rendering providers should have a basic understanding of compliant documentation, and how insurance payments work since they generate the claims. Whether we like it or not, we have to document, and clinical documentation of skilled services can be time consuming. Best of all, the transition for our entire staff was streamlined and consistent and help was readily available. CPT 97112 means "neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.". LEFS: 10% perceived impairment. (Examples for treatment provided would follow a similar format as noted above in the Daily Note Example. The patient will tolerate feeding self with minimal assist, occasional verbal cues and hand under hand technique 100% of meals with occupational therapy to maintain current weight at ______ lbs. The two most important PT/OT documentation requirements are demonstrating that care is (1) medically necessary and (2) skilled. poor foot clearance, improper hip alignment, impaired posture, increased stress, further irritation. hbbd```b``5 d``_ ,b&$X6 tLE$ H\, $:20m8LL z endstream endobj startxref 0 %%EOF 255 0 obj <>stream Increased time needed to execute and allow for therapeutic rest. 2021 PTProgress - Our content does not constitute medical, financial, or legal consultation. Its 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. Improving serratus activation through protraction will aid in upward rotation of scapulae., Instructed the patient on performance of stairs x5 with multiple cues to lead with the appropriate leg on descent., Instructed the patient on performance of stairs x5 without upper extremity support for simulation of home environment., The patient demonstrated ability to properly perform front step up in order to navigate stairs at home., The patient demonstrates poor body mechanics in lifting a 5# object to a shelf overhead. Master bedroom/bathroom is on the main floor. PT utilized Modified Borg Scale and patient reported 2/10 during exercise. PTs and PTAs are permitted to provide maintenance therapy services under Medicare Part A in home health and skilled nursing facility settings and across Part B settings. We continue to update this physical and hand therapy benchmark database by adding data from tens of thousands of visits each month. So wewantto treat patients butneedto document. PTs and PTAs still are expected to abide by existing rules that require the use of the CQ modifier when services are provided "in whole or in part" by the PTA. What is an example of an Ownership Change vs. a CHOW? 6 0 obj This may mean compacting the information that the patient has given you to get the information across succinctly. The Jimmo agreement (Jimmo v. Sebelius) settles once and for all that Medicare coverage is available for skilled services to maintain an individuals condition. Tim Fraticelli is a Physical Therapist, Certified Financial Planner and founder of PTProgress.com. Overall, patient completed x 15 minutes with PT directing patient with interval training of grading resistance 1-2 minutes. 4. The billing software is extremely versatile I can review number of claims sent / on hold, payer breakdown, charges per visit and collections per visit. A lot of therapists think that they can just cramp in a few notes after the sessions or write down what they remember within the week, but notes-taking, especially for therapy, doesn't work that way. All handwritten entries shall be made in ink and will include original signatures. Review these best practices for documentation to help you provide quality care, increase reimbursement, decrease denied claims, and articulate the distinct value of occupational therapy. Services that do not require the performance or supervision of a therapist are not considered skilled even if they are performed by a therapist. Ea{:Aml,wjrtvk|,lVxSdt=/].I=hiciUyl=ixSNI6} VD.a>U;ai>>T>.]SNmRLjYSJ. i&mAGOg ($+Gdb:Er?Y$jO8"LWIMRMnv#Z;"wjX${C4qI3T\b)dE5ln!?[*l Sign Up for a FREE Physical Therapy / Occupational Therapy Documentation Cheat Sheet!! Words/phrases that help document skilled care are listed below. All In Touch EMR customers get unlimited support via phone, email and live chat. Patient reported no increase in pain. 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. Patient needed stimulation . 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. To help therapists and assistants improve their documentation, the following are examples of documentation that clearly demonstrates the skilled nature of therapeutic exercise. step to] technique with physical therapy. Patient rates pain at 4/10 at present, 3/10 at best and 6/10 at worst. The patient will maintain the ability to perform toilet transfers at moderate assist level to prevent deterioration due to Parkinsons disease with significant intention tremors. Ex. Patient completed standing Achilles stretch 3x 30sec with mod verbal cues for technique and to engage in pain free range. Electronic entries are made with appropriate security and confidentiality provisions. Patient educated on purpose and instructed in Codmans exercise x 1-minute x 5 RUE clockwise, then counter clockwise. 5 0 obj Puthen Roy PT/OT Skilled Therapeutic Exercise Documentation Examples, Remote Therapeutic Monitoring by Physical and Occupational Therapists, North Carolina PT Board Position Statements March 2022. Balance: Rhomberg stance: positive; Single-leg stance: unable on Left, for up to 3 seconds on Right. The patient will identify potential fall hazards in path with potential loss of balance 80% accuracy through daily skilled intervention with physical therapy. Patient is active in his work as a floor manager at a local car manufacturer and could stand 8 to 10 hours a day, navigating stairs throughout the facility. The patient demonstrates lack of quad muscle recruitment. We also provide you with an option to download done-for-you templates for documentation. The information in this handbook is intended for therapy services for clients of all ages. I know because I, too, looked in vain for defensible documentation examples online. You may not have the time to read dozens of documentation examples, so I have included below an example of 4 types of notes commonly used in physical therapy.