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Effective documentation isn't about your practice: it's part of it.
Clinical documentation of patient and client management is a professional responsibility and a legal requirement. But it's more than just a record of services provided and outcomes to support payment for services: documentation is critical to ensure that individuals receive appropriate, comprehensive, efficient, person-centered, and high-quality health care services throughout the episode of care.
The resources below are rooted in APTA Board of Directors guidelines and evidence-based best practices.
Documentation Elements
Access the main documentation elements: initial examination and evaluation, visit, reexamination, and conclusion of episode of care summary.
Setting-Specific Considerations
There are many elements of documentation that need consideration; one of the most important is clinical setting.
Risk Management
Solid documentation can demonstrate that you met or exceeded the standard care and can help you mitigate your risks.