How to write a physical therapy progress note?

First, you note down the exercises you did during the session and why you did them. Then, write about how the patient responded to these exercises and any improvements you saw. You also mention what you plan to do next and when the patient should come back to see you.

Does therapy notes have templates?

Click Patients > Patient name > Documents tab To view all of the note templates that you have access to in TherapyNotes, click the Create Note button . A list of available note templates will appear.

How to write a good therapy note?

7 tips on how to write therapy progress notes Be clear, professional, and to the point. ... Use third-person, objective language. ... Back up your observations with clear evidence. ... Double-check information like date, time, place, and diagnostic code. ... Record any corrections formally. ... Use a note template. Aug 2, 2021

How do you write a simple progress note?

Progress notes record the date, location, duration, and services provided, and include a brief narrative . Documentation should substantiate the duration and frequency of service delivery. The narrative should describe the following elements: Client's symptoms/behaviors.

What is included in physical therapy notes?

SOAP Notes are a methodical way to document each visit, broken into four parts: the patient's personal report (Subjective), what is observed and measured (Objective), the therapist's analysis (Assessment), and the treatment plan (Plan) .

What not to put in a progress note?

Avoid making assumptions about patients ; this can limit your perspective and hinder effective care planning. Information overload: While thoroughness is essential, avoid including irrelevant details. Focus on concise and pertinent information directly related to the patient's condition and treatment plan.

What is required in therapy notes?

Document your patient's condition based on the descriptions they give you about why they decided to seek therapy. Objective: Include your notes on the client's appearance, body language, and any other notable detail that grasp your attention during the session.

What is the difference between a SOAP note and a birp note?

However, when comparing the behavior section to a SOAP note, the SOAP note documents client behavior in the subjective and objective areas. In a BIRP note, the therapist also documents specific interventions they use and how the client responds to them.

What do therapists write in their notes?

Your therapist uses what's in your current treatment plan to determine what they put in their notes. Progress notes are supposed to show how what you did in any given session addressed one or more of the goals on your treatment plan and whether you're making progress on them .

DAP is an acronym for Data, Assessment, and Plan. It is a simple and comprehensive template to help organize your notes. It is important to recognize that a DAP note is a progress note, not a personal psychotherapy note . That means it is part of the official record and can be shared with others.

What do therapy progress notes look like?

Progress notes cover three basic categories of information: what you observe about the client in session, what it means, and what you (or your client) are going to do about it . They can also be completed collaboratively with the client, to help establish a therapeutic alliance.

Do therapists have to write progress notes?

But therapists have to keep progress notes even if they don't take insurance . Why? Licensing law requires it. In fact, they can lose their license if they don't.

Physical Therapy Note Template & Example | Free PDF Download (2024)

Get this now

Use Template

Table of content

What is a Physical Therapy Note Template?How to Use This Template For Physical Therapy NotePhysical Therapy Note Example (Sample)Who Can Use this Printable Physical Therapy Note Template?Benefits of Physical Therapy NotesWhy Use Carepatron For Physical Therapy Notes?FAQs

What is a Physical Therapy Note Template?

Clinical documentation is an inherent aspect of working as a physical therapist. In addition to the legally required progress notes, physical therapists may also write more general notes. These documents could contain the physical therapist’s thoughts, ideas, observations, and hypotheses about their session with a patient. Essentially, these types of notes serve the primary purpose of being a reference point for the therapist, who can check over them and ensure they are making the most appropriate treatment decision. are not legal documents and are not designed to be shared with third-parties. While this means they can be more subjective, they still contain PHI and consequently, must still be protected. After you have written your physical therapy notes, you are required to store them in a HIPAA-compliant manner in order to protect the privacy of your patients.

Physical therapists are often very busy healthcare practitioners, and are looking for ways to ease their workload without compromising the quality of their care delivery. This is why we’ve created our note template. You can download the PDF template for free and store it on your computer, where it can be accessed at a later date. As you’ll see, using note templates has a vast range of advantages for physical therapists, and they can help elevate accuracy, organization, and most importantly, clinical outcomes.

Click here to view on YouTube

Printable Physical Therapy Note Template

Check out these note templates for physical therapy to improve clinical documentation, productivity, and treatment outcomes.

Download TemplateDownload Example PDF

How to Use This Template For Physical Therapy Note

Fortunately, using this physical therapy note template is very simple. In order to get the most out of this resource, follow these three steps:

Save the PDF template

We’ve included a link to the PDF template on this page, and you simply have to click on the link and you’ll be taken directly to the document. You can easily edit the template from this page, or you can choose to download and save it to your device. You also have the option for printing, if you’d prefer to write on a physical copy.

Write your notes

After you have had a session with a patient, it’s time to write your physical therapy notes. In order to guarantee your notes are as accurate as possible, it’s a good idea to write your physical therapy notes immediately after a session with a patient. This means the information will be fresh in your mind, and you won’t forget any important details.

Store securely

Once your notes have been written, they need to be stored securely. As we mentioned before, physical therapy notes contain confidential information so they need to be stored in a way that protects patient privacy. Depending on how you’ve written your notes, you can either store them online using an EHR, or in a physical location. While both of these options are perfectly fine, we recommend using an online storage method, as these usually have very effective safeguards as well as being easily accessed by authorized users.

Apply them to your work

The key to writing clinical documentation is understanding that the work doesn’t stop after you’ve written the note. In order for physical therapy notes to have the desired effect, you need to utilize them in your future sessions with patients. You should be accessing these notes and using the information that is recorded to better inform your decisions.

Physical Therapy Note Example (Sample)

To help you visualize what this note template looks like in action, we’ve created a sample document based on a fictional physical therapy session. In it, we’ve recorded details pertaining to the session so you can get an insight into how information is structured in these kinds of notes.

Download thisPhysical Therapy Note Examplehere:

Who Can Use this Printable Physical Therapy Note Template?

Within the physical therapy field, there is a range of different specializations and techniques employed by practitioners. While the methods of these therapists evidently differ, the structure of their clinical note-taking can largely remain the same. For this reason, our physical therapy note template is applicable to physical therapists who have various specializations, including the following:

Occupational physical therapy
Rehabilitative physical therapy
Pediatric physical therapy
Geriatric physical therapy
Orthopedic physical therapy
Neurological physical therapy

Additionally, our physical therapy note template is suitable for all practitioners, regardless of their experiences. Therapists who have been in the field for decades will find our template useful in improving their organization and efficiency, just as young and in-training physical therapists will benefit from the improved structure and accuracy.

Why is This Template Useful For Physical Therapists?

This note template has a range of different uses to assist with the day-to-day lives of busy physical therapists:

Organization: Using a note template to write your documentation is extremely useful when it comes to organization. With a predesigned format, you can ensure your notes are well-organized and easily read.
Accessibility: Because our note templates can be edited online and stored either on your own device or in an EHR system, they are extremely accessible. When you need to quickly check your documents or refer to a previous session, you can simply navigate to wherever you store your notes and the information will be presented before you.‍
Saves time: One of the best aspects of our physical therapist note templates is how much time they will save you. You no longer have to worry about doing any of the formatting, as the document is available with a few simple clicks. The time that you save by using our template can instead be spent completing more pressing tasks, like seeing and treating your patients.

Why Use Carepatron For Physical Therapy Notes?

Using practice management software to streamline clinical documentation is one of the best decisions you can make for your physical therapy practice. Carepatron, an all-in-one system, is designed to optimize a range of administrative and clinical processes. The platform has an extensive library of resources and clinical note tools including voice-to-text transcription software, saving you significant amounts of time. Additionally, Carepatron offers you a place to store your documents – with all of the safeguards in place to guarantee it is HIPAA-compliant.

If you are looking for a platform that offers more than just documentation assistance then Carepatron may be the right solution. The system is integrated with medical billing, coding, patient engagement, scheduling, appointment reminders, and mobile health features, all of which allow you to focus on delivering the best quality healthcare to patients in need. By investing in Carepatron, you will be able to elevate the accuracy of the processes at your physical therapy practice, all while saving time and resources.

How do you format a physical therapy note?

Commonly asked questions

How do you format a physical therapy note?

Unlike a progress note, there is no expected format for a physical therapy note. They aren’t technically legal documents so how they are structured is largely up to the physical therapist. For this reason, we’ve created a template that is reasonably adaptable so you can structure your notes in whatever way suits you best.

Why do physical therapists take these session notes?

There are a few reasons why physical therapists take session notes, but the most important one is so that they remember important information. Physical therapists may write these records so that the next time they have a session with a patient, they simply have to read their notes and they will be reminded of the details regarding that patient’s concern. Organizing this kind of information helps to ensure physical therapists remain informed at all times.

Can patients view physical therapist notes?

The simple answer to this question is no, patients can’t view physical therapist session notes. However, there are some (very rare) cases where patients can apply to view these private notes and may be granted access.