Skip to main content

What follows is a description of the main documentation elements of patient and client management: initial examination and evaluation, visit, reexamination, and conclusion of episode of care summary.

Please note that the added webpages linked below offer additional guidance specific to pediatric patients and clients when protocols and practice may differ from managing adults. These sections are identified at the end of various sections throughout this resource.

Additionally, be sure to reference the companion article, Documentation: Risk Management, for related information.

Log in or create a free account to keep reading.


Join APTA to get unlimited access to content.


You Might Also Like...

News

What You Were Reading: Five Top PTJ Articles in 2024

Jan 27, 2025

The most popular studies in APTA’s scientific journal, PTJ: Physical Therapy & Rehabilitation Journal, covered a wide range of topics.

News

CMS Releases 2026 Medicare Advantage Proposed Rule

Jan 24, 2025

Increased transparency and clarity around coverage criteria are intended to improve protections for MA beneficiaries.

Review

For Mild Concussion, Early Physical Therapy Brings Best Outcomes

Jan 22, 2025

APTA's scientific journal made headlines with its study on early treatment for mild traumatic brain injury. Here are the highlights.