PHYSICAL THERAPY DOCUMENTATION

as the patient?s diagnoses, complicating factors, age, severity, time since onset/acuity, self-efficacy/motivation, cognitive ability, prognosis, and/or medical, psychological and social stability.

Changes in objective and sometimes to subjective measures of improvement also help establish the need for rehabilitative services The use of scientific evidence, obtained from professional literature, and sequential measurements of the patient?s condition during treatment is encouraged to support the potential for continued improvement that may justify the patients need for rehabilitative therapy or the patient?s need for maintenance therapy

Only an excerpt is provided above. The Manual continues for many pages with requirements for Evaluations and Re-evaluations, Progress Notes, Functional Reporting, etc