18-26. PMM and Documentation Combined

APTA Guide to Physical Therapist Practice (v 4.0 – 2023)

• History & Origin

  • Early 1990s – U.S. state legislatures request "practice parameters" from health professions.

  • Feb 1992 – APTA Board of Directors initiates development of a unifying practice document.

  • 1997 – First edition of “The Guide” published following House of Delegates (HOD) approval.

• Purposes of the Guide

  • Describes physical therapist (PT) practice & roles.

  • Standardizes professional terminology.

  • Delineates clinical decision-making: Examination → Evaluation → Interventions → Outcomes.

  • Serves members, policy makers, and third-party payers.

• Table of Contents (macro-view)

  1. Introduction.

  2. Accessing PT services & Patient/Client Management elements.

  3. Examination & Evaluation.

  4. Diagnosis, Prognosis, Intervention, Outcomes.

• Who Are PTs?

  • Health professionals who diagnose/manage movement dysfunction to restore, maintain, & promote optimal function across life span.

  • Possess unique movement-science knowledge base.

• Core Concepts & Commitments

  • Evidence-based practice.

  • Quality assessment & outcomes measurement.

  • Professional values & ethics.

  • Continuous quality improvement.

• Biopsychosocial & ICF Frameworks

  • Health status = interaction of biological, psychological, social domains.

  • ICF links impairments ↔ activities ↔ participation; underpins PT documentation & goal setting.

Accessing Physical Therapist Services

• Modes of Entry

  • Self-referral / Direct access (varies by state practice act).

  • Referral from another provider or PT.

  • Intervention for a specific condition.

• PT Decision-Making Options

  • Co-manage – coordinate with other professionals.

  • Consult – expert opinion/recommendations.

  • Manage – remain accountable for delegated services.

  • Refer – services outside scope or for specific testing.

• Episode of Care / Visit

  • Episode = all PT services provided in an unbroken sequence for a given problem.

  • Visit = single encounter/session.

• Consumers of PT Services

  • Patients – receive PT for disease, disorder, etc.

  • Clients – seek consultation, wellness, prevention (e.g., businesses, schools).

  • Communities – groups with shared interests.

  • Populations – demographic collections (ethnicity, SES, density).

Patient & Client Management Model (Six Elements)

• Examination → Evaluation → Diagnosis → Prognosis → Intervention → Outcomes (with potential Referral/Consultation at any point).

Examination (Element 1)

• Components

  1. History (subjective interview, questionnaires, record review).

  2. Review of Systems (ROS) – screening of major body systems.

  3. Physical Examination / Systems Review – limited hands-on screen.

  4. Tests & Measures – objective, standardized, quantifiable.

• Subjective History – gather demographics, chief complaint, previous level of function, meds, diagnostics, social/health behaviors.

• Red Flags (trigger referral)

  • Example – Stroke FAST:

  • Face droop, Arms weakness, Speech slurred, Time to call 911.

• Review of Systems – Medical History Checklist

  • Cardiovascular, Pulmonary, Endocrine, EENT, GI, GU/Reproductive, Hematologic/Lymphatic, Immune, Integumentary, Nervous, Musculoskeletal, General (weight change, fatigue, mood).

• Physical Examination – Initial Screening

  • Cardiopulmonary (vitals, edema).

  • Integumentary (color, integrity).

  • Musculoskeletal (gross ROM/strength, symmetry).

  • Neuromuscular (balance, gait, transfers).

  • Communication/Cognition (orientation, learning style).

• Tests & Measures (26 Categories)
  Aerobic capacity, Anthropometrics, Assistive technology, Balance, Circulation, Cognition, Community/Social life, Nerve integrity, Education life, Environment, Gait, Integument, Joint mobility, Locomotion/Mobility, Motor function, Muscle performance, Neuromotor dev., Pain, Posture, ROM, Reflexes, Self-care, Sensory, Skeletal, Ventilation/Respiration, Work/Community integration.

• Measurement Properties

  • Reliability – consistent results over time.

  • Validity – measures what it claims.

  • Self-report vs. Performance-based.

• Outcome Measures – standardized tests used pre-/post-episode to quantify change (e.g., functional status, impairments, morbidity, satisfaction).

Evaluation (Element 2)

• Interpret/synthesize findings ⇒ establish PT diagnosis, determine prognosis & goals, craft management plan, decide on need for referral.

Diagnosis (Element 3)

• Label reflecting clusters of signs/symptoms or impairments/activity limitations/participation restrictions.

• Guides selection of interventions.

Prognosis & Goals (Element 4)

• Prognosis – predicted optimal improvement level & timeframe; influenced by contextual factors (age, comorbidities, environment, SDOH).

• Goals – measurable, time-bound impacts on function; classified short-term (STG) & long-term (LTG).

  • Primary discharge criterion = achievement of goals.

Intervention (Element 5)

• Purpose – remediate impairments, enhance function, promote health/wellness.

• Complexity Factors – psychosocial, economic, health status, adherence.

• Procedural Categories

  • Therapeutic exercise.

  • Motor function / movement training.

  • Functional training (incl. ADL, gait).

  • Manual therapy techniques.

  • Biophysical agents.

  • Integumentary repair/protect.

  • Respiratory & ventilatory techniques.

  • Adaptive & assistive technology.

• Prevention Levels – Primary (prevent injury/disease in healthy population).

Outcomes (Element 6)

• Actual results of plan implementation; demonstrate progress, justify payment, signal goal attainment.

• Document via repeat tests & measures.

Clinical Problem-Solving Framework

• Problem List

  • Patient-identified (usually functional).

  • Non-patient-identified (caregiver, team, objective findings).

• Problem Types

  • Impairments (body function).
    – e.g., ↓ strength, ↓ ROM, balance deficit.

  • Activity limitations (functional tasks).
    – e.g., bed mobility, gait.

  • Participation restrictions (life roles).
    – e.g., work duties, driving.

• Linkage Chain
  Problems ↔ Tests & Measures ↔ Goals ↔ Interventions.

• Justification – must measure a problem for it to become a goal or receive an intervention.

Goal-Writing Principles

• SMART → Specific, Measurable, Achievable, Relevant, Time-bound.

• Short-Term Goals (STG) – days/visits; build toward LTGs.

• Long-Term Goals (LTG) – expected outcome at discharge; meaningful & functional.

Documentation – Importance & Principles

• Why Document?

  • Legal record, clinical reasoning transparency, regulatory compliance, reimbursement, research, policy, risk management.

• APTA Statement – Documentation must reflect PT thought process & decision-making.

• Abbreviations

  • Use sparingly; adhere to facility list; Joint Commission “Do Not Use”: U, IU, Q.D., Q.O.D., trailing zeros, MS, MSO4, MgSO4.

General Guidelines

• Clear, complete, concise; minimal abbreviations.

• Quantitative & objective; no blank lines (use "NT" if not tested).

• Professional tone; correct spelling; HIPAA compliance.

• Signature/credentials (e.g., Jane Doe SPT); date/time; treatment codes & minutes if required.

• Informed Consent – discuss interventions, risks, benefits, alternatives.

Types of Documentation

• Initial Examination/Evaluation – full PCM elements.

• Daily (Visit/Encounter) Note – every session.

• Progress / Re-evaluation Note – typically every 30{-}60 days or when status changes.

• Discharge / Discontinuation Summary – end of episode.

Initial Examination Template Highlights

• History (subjective, ROS).

• Systems Review (hands-on screen).

• Tests & Measures – organized tables.

• Evaluation/Clinical Impression → Diagnosis, Prognosis, Plan of Care.

• Interventions initiated.

• Functional Goals.

Daily Note Components (SOAP format)

• S – Patient self-report.

• O – Interventions provided (frequency, intensity, duration, assistance); objective changes.

• A – Skilled assessment, clinical reasoning, progress toward goals.

• P – Plan for next visit (progressions, education, precautions).

• Additional: cancellations/no-shows, equipment issued, communication with team.

  • Document skilled care: type/amount of cues, clinical decisions, functional relevance.

Progress Note

• Compare status to previous notes & initial exam.

• Re-test original measures; update goals & interventions; revise POC; justify continued therapy.

Discharge Evaluation

• Required elements:

  • Reason & date of episode conclusion.

  • Objective & subjective status.

• Include: goals achieved/unachieved (with reasons), outcome measure scores, HEP, equipment, referrals, caregiver training, visit count, justification of medical necessity.

• Example progress table:

  • Berg Balance 40\to52 (no longer high fall risk), Gait Speed 0.5\to1.0\;m/s (now unlimited community ambulator).

SOAP Note Deep Dive

• Subjective – problems, goals, response to prior treatment.

• Objective – ROS, meds, imaging, systems review, tests & measures.

• Assessment – synthesis of impairments, activity limits, participation issues; need for skilled PT.

• Plan – frequency/duration, intervention strategies, education, equipment, referrals, discharge disposition.

• Flowsheets – concise parameter/response tables:
  Exercise → sets/reps, load → tolerance;
  Gait → distance, device, assistance → quality;
  Modalities → settings → physiologic response.

Ethical, Philosophical & Practical Implications

• Transparency & accountability – documentation as ethical duty.

• Patient-centeredness – goals & interventions align with patient values.

• Interprofessional communication – accurate notes prevent errors & foster collaboration.

• Data-driven practice – standardized measures enable outcomes research & health policy advocacy.

• Legal protection – thorough, timely records safeguard clinicians & patients.

Numerical / Statistical References & Formulas

• Red Flag Stroke mnemonic – FAST.

• No complex formulas presented; measurement properties conceptual (Reliability \neq Validity).

Connections & Real-World Relevance

• Direct access legislation dictates examination thoroughness (must screen for red flags).

• Reimbursement models (e.g., value-based purchasing) hinge on documented outcomes.

• Quality measures recorded by PTs feed national databases influencing policy & payment.

• Documentation standards mirror other rehab disciplines promoting cohesive team care.

Quick Reference Tables (Suggested for Study Sheets)

• 26 Test & Measure Categories – memorize clusters.

• Procedural Interventions – match to ICF impairment/activity levels.

• SOAP vs. PCM Element Mapping – Examination → S/O, Evaluation → A, Plan → P.

• Abbreviation Red List – know Joint Commission “Do Not Use”.

End of comprehensive bullet-point study notes.