Guide To Patient Charts

Patient Chart Components and Descriptions:

-Paperwork (Left side of Chart)-
Hippa Form:
o A form explaining hippa confidentiality to the patient and a place for the patients signature.
Insurance Verification Form:
o Form that includes the patients current insurance plan, which includes how many treatment
sessions are covered, any co-pays for sessions, and secondary insurances can be listed. It is also
signed by the patient.
New Patient Information Form:
o This form includes the diagnosis of the patient and when the symptoms started, a diagram of
where the pain or pins/needles is located, a medication list, a list of scans done for the injury, and
their preferred language. This document is signed by both the patient and the therapist.
General Consent Form:
o This form is signed by the patient. It gives consent for the therapist to treat the patient. If the
patient is a minor, it is signed by their guardian.
Insurance Referral:
o Some insurances require a referral for a patient to have therapy.
DC Questionnaire:
o This document is filled out by a therapist at the time of discharge. It is a checklist of the
components of the patients chart. The checklist highlights medicare billing lists, therapists and
physician signatures, and the physician script for therapy.
Precautions/Contra-indications Form:
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o This form is required by the hospital. It includes a list of precautions for the persons injury, a list
of allergies, and any psychiatric disorders.
Medicare Billing List:
o This is a list where billing from treatment sessions is recorded.
Calendar:
o This is used to record visits for Medicare or insurance purposes.
-Paperwork (Right Side of Chart)-
Treatment Note:
o The patient treatment note for each session.
Plan of Care Note:
o This note is sent to the patients physician. It includes the therapists measurements and report on
the patients current level.
Fax Transmittal:
o The cover letter used to fax a plan of care note or a communication note to the physicians.
Foto Summary:
o This is a summary of an iPad survey taken by the patient. It includes questions on tasks that one
can or cannot perform with their symptoms. The software calculates the patients level of
mobility.
Re-Evaluation Note:
o This is the therapists detailed account of the follow up with the patient. It includes the previous
and current measurements as well as the patients overall function.
Missed Visit Note:
o If a patient misses a treatment session it is recorded and signed by a therapist. This note includes
a summary of why the session was miss Ex: no show, illness, rescheduled. There is a statement
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included on the status of the treatment session. If it is their second no show or third cancel
treatment is suspended.
Initial Evaluation Note:
o This note includes the measurements and description of the patients initial
evaluation/examination. The therapist records all of the measurements and tests performed as
well as what the patient states about their symptoms.
Patient Medical History:
o This is a chart required by the hospital. It includes the medical history of the patient as well as
their mother, father, and siblings. Any allergies or previous surgeries are also listed.
Patient Medication List:
o A list of patients current medications including dosages and daily intake records. It is also noted
what the medications are taken for.
Home Exercise Chart:
o The recorded copy of a patients at home exercise chart.
Protocol:
o The copy of the patients rehabilitation protocol provided by their physician. *Usually for
tendon/ligament repairs.
-Specific Therapy Note Descriptions-
Treatment Note:
o PT Interventions and CPT Codes Consisted of:
What type of treatment occurred during the patients session that day. This can include:
an initial evaluation, a re-evaluation, manual therapy, cold or hot pack therapy,
modalities, manual therapy, and therapeutic procedure. The billing code for the insurance
companies is also included along with the time spent on each intervention. Each
intervention includes a number of units which is then totaled along with the time.
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o Intervention Comments:
This is where the patients insurance is stated as well as which billing/coding protocol to
follow. If the patient has a specific rehabilitation protocol from their physician it is listed
here along with their phase number. The diagnosis the therapist found can be found here
along with their manual therapy specifications.
o Progressive Exercises:
The treatment exercises for the patients session. This section includes the exercise, the
type of weight/theraband, time, sets, and repetitions.
o Functional Characteristics and Analysis:
This section includes the report that the patient gives you at the beginning of their
session. This can include their symptoms, their level of pain, an update from their
physician, an update on their daily home exercises, and anything significant that they
inform you about.
o Impairment Observations:
This section includes what you observe during the treatment session. If they have
difficulty with an exercise or it causes pain the therapists notes it here. Any suggestions
for different exercises or progressions is also noted here.
Initial-Evaluation/Examination Note:
o Rehabilitation Information/History:
This includes the patients background medical history as well as their prior functioning
level. The physicians diagnosis code is also documented here. Therapy restrictions as
well as the reason for therapy are also included in this section.
o Physical Findings:
In this section the therapist notes the location of the pain, the pain level at rest, the pain
level with activity, the characteristic of the pain, and activities that cause the pain. This
section also includes two charts of measurements documented by the therapist. The chart
categories include: strength, active ROM (AROM), and passive ROM (PROM). One
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chart is data from the initial evaluation and the other chart is the patients goal
measurements.
o Impairment Observations:
This is where the therapist reports what the patient described to them about the
mechanism of injury. They record how the injury occurred, the description of the pain,
the patients daily tasks that are inhibited by the injury, and what the patients goals are.
o Functional Characteristics and Analysis:
This is where the therapist records their findings from the examination. They report their
diagnosis for the patient, what they observe during the session, how long they suggest the
patients therapy should last, and how they feel the therapy will affect the patient.
o Goals:
This section includes Impairment goals (short term) and functional goals (long term). The
short term goals include tasks such as pain level, ROM, and weight bearing. The long
term goals include maximal function of functional movements such as walking, stair
climbing, reaching overhead, and lifting.
o Interventions:
A list of the type of interventions as well as their codes. This includes: Session type
(initial evaluation, re-evaluation, treatment), therapeutic exercises, modalities, and
manual therapy. The duration of therapy and number of sessions a week is also noted
here.
Plan Of Care [Re-Evaluation] Note:
o Current Level:
This section includes the patients current pain levels, pain locations, and pain
descriptions.
o Goals:
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A list of the therapists short term goals for the patient as well as the long term goals.
Examples include: Decreased pain by 25% in 4 weeks; Pt will be able to perform self-
care duties with <5/10 pain in 4 weeks. The therapist will note after the goal if it was met,
or partially met.
o Functional Characteristics and Analysis:
This section reports how the patient feels at this time. They will record what the patient
has to say about their status compared to their last re-evaluation or initial evaluation. The
therapist records the tasks that they had difficulty with 4 weeks prior and how they
function with them now. Their goals for therapy are also recorded here.
o Specific Joint Measurements:
This section provides two charts of measurements. One chart is of the initial evaluation or
previous re-evaluation measurements and the second includes the measurements taken at
the re-evaluation. There is also a sub section that includes comments about the details of
the measurements. This describes which position they were taken in as well as any
special tests that were performed.
o Interventions (Codes):
A list of the type of interventions as well as their codes.
o Impairment Observations:
This is the section where the therapist reports his findings from the re-evaluation. They
note any improvements to the patients range of motion, pain level/symptoms, and
strength levels. Their recommendation for future treatment sessions is also reported.