Physical Therapy Notes: What to Know for Practitioners

Notes are key in any medical practice, but in rehab and physical therapy, they’re crucial to understanding your patients and cultivating relationships. When therapists see patients once a week, or even more frequently, notes are important to track progress over time. These notes placed in medical records allow physical therapists (PTs) to quickly recall how a patient performed in a specific session and to follow healing between sessions.

If notes are so important, why are there still questions out there about physical therapy notes? Shouldn’t there be a standard that all PTs follow to reduce any confusion about their notes and their patient’s treatment? What makes these notes so important, and why should PTs care? Let’s dig in.

What Are Physical Therapy Notes?

Physical therapy notes are the documentation and impressions that PTs and physical therapy assistants (PTAs) create surrounding their sessions with patients. The idea is to craft notes that easily jog the PT’s memory, making continuing care of patients simpler, less time-consuming, and more effective.

Notes are widely used across the medical profession by all kinds of practitioners. They’re sometimes even shared between disciplines, especially if a patient is being treated for multiple conditions or has multiple stages of recovery. In the case of physical therapy, you might see notes from an orthopedic surgeon who just did a total knee replacement and is now passing that patient along to you for post-therapy rehab.

How Do Physical Therapy Notes Work?

We’re in the digital age now, and the good news is PT notes have joined it as well. Most notes are digital these days, which means they’re generally recorded in your clinic’s electronic medical record (EMR). EMRs track medical care, from services provided to tests run to medical history, so it only stands to reason that they would also track session and appointment notes.

The more efficiently your EMR captures and recalls your session notes, the easier of a time you’ll have connecting with your patients. Notes that are more detailed make it both easier to remember what you may have discussed with your patient in the last session and to connect with them on a personal level. After all, connecting with them is a major part of the job.

Are There Different Types of PT Notes?

PT notes can technically come in any format—since these are just meant to document sessions, practitioners can take notes however they find easiest to follow when they look back over them. One of the most common methods is the SOAP note, a methodology developed over 50 years ago to create an organized note-taking structure. It includes subjective, objective, assessment, and plan information to monitor all types of relevant material as the patient progresses.

However, SOAP notes aren’t the only way to use a structure to take notes. Any process or template that includes the information that you need to adequately treat your patients is a winning strategy.

What about OTs and SLPs?

Yep, occupational therapists (OTs) and speech-language pathologists (SLPs), who also fall under the general umbrella of rehab therapists, also use session notes. They typically have different goals and a different scope of treatment, but they’re just as concerned as PTs with keeping diligent, consistent, helpful notes.

The good news is that this means if your clinic encompasses all three, PTs, OTs, and SLPs, a single EMR should work for all of them.

Challenges for Physical Therapy Notes

Note-taking is not without its challenges, simple as it might seem on the surface. Potentially, the biggest challenge for practitioners is the time it takes to craft adequate notes. Some PTs are seeing over a dozen patients a day in particularly busy locations, some are exclusively seeing complex cases that may require more extensive notes… it can be tricky to find the time for proper note taking.

If you had all the time in the world, you might take incredibly detailed notes, recording how a patient felt overall, how they performed on each exercise, any concerns they raised, what you sent them home with, and any number of other observations about the session that might help you jog your memory later. In turn, more detailed notes might mean you’re better able to treat your patients.

Interfacing with Hospitals and PT Clinic Systems

Depending on your clinic’s setup, time might not be the only note-taking constraint you deal with. If you’re a clinic in a hospital, your EMR might be the hospital’s general EMR that isn’t tailored for your rehab therapy needs. If you’re in a system with multiple locations, sharing patients between locations or therapists means you need notes that will be available at both locations. At minimum, the staff that splits their time between different locations might be driven a bit crazy by having to know two different note-taking and documentation systems.

While these are the main concerns for PTs in their note-taking efforts, they aren’t the only complications.

Other challenges PTs may face in taking adequate notes for patient sessions:

• Compliance in all notes and documentation
• Procrastination and motivation (we know, notes are not the most interesting part of your job, and you probably struggle to get them done)
• Clinic expectations

Is There a Better Way to Do PT Notes?

One thing is for certain: better notes do mean better treatment for your patients. But that doesn’t mean they have to be long, incredibly detailed, or eat up hours of your day. It doesn’t mean you have to stress over compliance or worry so much you put off your documentation for days. There are some strategies to employ to alleviate the more complicated aspects of PT notes.

Know Your EMR

The EMR you use can make a huge difference in the quality and efficiency of your documentation. The right EMR will keep you on time and can help make sure your notes are consistent across patients and over time.

Compliance

One of the biggest upsides of a good EMR is that it will help keep your documentation compliant. Compliance means less risk of problems with reimbursement, potentially higher reimbursement, and less stress overall—imagine, a world where you don’t have to go through all the headache of compliance on your own. On top of all that, an EMR with compliance in mind means you can create defensible documentation, often in just minutes.

Customization

If you’re in a hospital, you might be using an EMR used by the entire hospital. Which means it’s not exactly optimized for rehab therapy. A PT- or rehab therapy-specific EMR should be a better fit for your needs, and it might make all that documentation smoother and simpler. Some PT EMRs will scale to work across many clinics in an organization, which means everyone in the organization can be onboarded the same way onto the same EMR.

Not to mention that templates, widgets, and shortcuts can make a huge difference in the ease of documentation. Tailoring your EMR means that you can:

• Quickly and easily generate notes
• Include the same content in each note
• Focus on important information and compliance

Just Write Less

Seriously, the key might just be to write less. It might sound like we’re advocating for slacking off, but less volume doesn’t have to mean worse quality. Think about it like you’re keeping a journal of the last month of your life. Many days probably looked like this:

• Send the kids to school
• Work
• Take the kids to after-school activities
• Dinner and chores
• Go to bed

You’re not going to record much about most of those days. You’ll probably say something like “Good day. Katie aced her math test.” If something particularly good or bad happened, that’s when you’ll note it in more detail, like, “Tim got a band award for best trumpet in the sophomore class.”

That’s the same principle you can apply to your notes. If everything is standard, standard verbiage should be enough to qualify the session. If anything stood out, whether progress or a setback, those are the things to focus on in your notes. This approach will save you time and help you recall the big stuff from session to session.

Another thing to keep in mind here: keyboard shortcuts are your friend. Setting up hotkeys or shortcuts that will auto-populate based on a few letters will save you time in phrases you use regularly. If you find yourself often saying “patient tolerated treatment well” or “patient would benefit from continued focus on [insert treatment],” it might be worth setting up those shortcuts. If you have to fill in blanks, that’s okay—the base of the sentence is already there.

Shortcuts also make it easier to add detail. If you can fill in a few sentences with shortcuts, all the time you would have spent on those is free to add some detail. In the long run, that should help you better recall the information you need to remember from the note.

Document While You Treat

This one might be the most difficult to accomplish. PTs are busy, and your sessions might not leave room for note-taking time, especially if you want to actually engage with your patient. But really, what better way to save time and be accurate than to take notes during the session?

If you’re applying tips one and two already by using a template in a PT-specific EMR with keyboard shortcuts to a few key phrases, you can take a few seconds between exercises to record how the patient is performing. Over the course of the session, this could add up to the time it takes to craft a quality PT note.

Other good times to take notes?

• While the patient is working with a PTA
• Between sessions
• While the patient is on a break, like getting a drink of water or going to the bathroom

Just keep in mind that you can’t bill for documentation time (though there are plenty of natural breaks in a session you’re already not billing for that would leave room for documentation).

What Does a Good PT Note Look Like?

SOAP notes might not be the only method to take PT notes, but they do make for a good example of easy, straightforward note-taking.

Here’s what a SOAP note for an evaluation might include.

• Subjective: Patient reports lower back pain from a sports injury with the onset of symptoms four months ago with little improvement. Sharp pain when flexing past 30°, pressing through left leg, and occasionally extending forward. Pain is somewhat managed with medication. Patient aims to reduce back pain and return to prior sports activities without pain.
• Objective: Patient lifts left hip off floor when tensing abdominals. Patient can hold a plank for 53 seconds. Patient scored 2+ on manual muscle strength left hip flexion test and a 6/10 VAS for pain.
• Assessment: Patient is unable to properly engage abdominals, resulting in spinal rotation and weakness under stress. Patient exhibits likely strain of erector spinae and psoas. Injury is likely to improve with therapeutic intervention and pain management. Patient is likely to return to prior activities without significant interruption.
• Plan: Treatment will focus on strengthening lower abdominals, erector spinae, and psoas and other hip muscles through stabilization and strengthening exercises. 2 sessions per week for the first 6 weeks, with reassessment planned in the 7^th week. Treatment will be adjusted to accommodate patient’s progress.

For a given session during treatment, you might make these changes.

• Subjective: Therapeutic treatment has improved pain while extending and pressing through left leg.
• Objective: Patient’s range of motion at the left hip and lumbar spine have steadily improved with treatment.
• Assessment: Patient’s treatment is progressing well. The strength of the erector spinae and psoas have increased.
• Plan: Continue patient’s treatment, increasing difficulty and introducing new exercises in accordance with patient’s increased range of motion and strength.

PT Notes Are the Key to Quality Treatment

PT notes are a key aspect of documentation for any rehab therapy clinic, but they’re not always easy-breezy. With limited time and many regulations to be compliant with, taking proper notes that will actually help your patients can feel like a bit of a minefield. But fear not, there are tips to manage these mitigating factors, like documenting while you treat, writing down just the important stuff, and working with a top-notch, PT-specific EMR.

The best EMRs will let you customize your own templates, set up shortcuts to make note-taking quicker and easier, be specific to physical therapy’s needs, and integrate with the rest of your hospital system or scale to the extent of your organization.

Notes are a major factor in building new relationships and connecting with your patients. Knowing exactly what you last discussed and when in a pinch is one of the best ways to cultivate those relationships with your patients. And after all, isn’t that one of the best parts of PT?

So don’t worry: with these strategies by your side, PT notes just got a lot easier.