For each date a patient is seen, what must a PT document?

In the context of physical therapy documentation, it is essential for a physical therapist (PT) to record all therapeutic interventions that require their expertise during each patient encounter. This documentation serves multiple purposes, including ensuring continuity of care, providing a clear record for insurance and legal needs, and facilitating communication among healthcare providers.

By documenting all interventions, the PT captures the specific modalities, techniques, and exercises applied during the visit, which not only reflects the clinical reasoning behind the treatment plan but also establishes a baseline for measuring patient progress. Proper documentation of therapeutic interventions ensures that the therapy provided is aligned with best practices and professional standards, as it showcases the application of specialized knowledge and skills unique to the field of physical therapy.

This practice is not only vital for quality patient care but is also a requirement under various regulatory and accreditation standards governing physical therapy practice. Therefore, documenting all therapeutic interventions is a fundamental responsibility of the PT that directly contributes to patient outcomes and the professional integrity of the physical therapy discipline.