Documentation and Charting

What must you do with every client-therapist contact

All contact with clients/athletes must be documented and kept according to PHIA standards

What is PHIA

Personal Health Information Act

What does PHIA look over?

• Storing of records

• Sharing information with other professionals

• Disclosure and use

What should be included in your documentation

• Examination and assessment notes

• Reexamination and reassessment notes

• Each treatment session details

• Physician progress notes

• Patient responses to treatments

• Patient home instructions/directions

• Discharge summary

How to organize your documentation notes

SOAP Notes

What does SOAP stand for

Subjective Objective Assessment Plan

What must you do with your documentation findings and treatment goals?

You must always take the time to communicate your findings & treatment goals with the client, make sure they understand and are in agreement.

During subsequent visits what must you document

• Document clients’ current condition, symptoms, changes

• Update ROM, Strength changes (as necessary)

• Document client’s response to previous treatment and rehab plan (pain, swelling, difficulty)

• Document new treatment plan for that visit

what is different clinic to clinic with their documentation

Institutions/companies may have specific forms or programs.

are records legal documents?

All records are legal documents.

What is important in maintaining documents

• Record legibly and accurately.

• Use professional terminology.

• Maintain records in secured location.

• Abide by legal requirements for storage, maintenance & disposal.