Skilled PT Documentation

Skilled PT Documentation Template

Subjective:

“Pt reports [pain, stiffness, fatigue, dizziness, fear of falling, progress with HEP, etc.]. Patient states [barrier/success/challenge] with [functional task].”

Examples:

• “Pt reports increased low back pain when rising from chair; now limiting activity to 1x/day.”

• “Pt reports confidence with rollator use indoors but avoids outdoor ambulation due to fear of inclines.”

Objective:

Objective means “not influenced by personal feelings or opinions in considering and representing facts.”

These are assistance levels for ADLs, MMT/strength levels, ROM, vitals, balance, transfer assistance levels. 

Skilled Care Provided:

1. Functional Task or Exercise Performed:

“Pt participated in [task/exercise] targeting [impairment or functional goal].”

2. Clinical Decision-Making & Grading:

“PT modified [speed/position/cueing/task/environment/resistance] due to [pain, balance, endurance, safety concern].”

3. Focus Area (view “Examples of Strong, Skilled PT Documentation Phrases”) :
🟡 Gait Mechanics
🔵 Balance & Fall Risk Reduction
🟢 Transfers & Body Mechanics
🔴 Functional Strengthening
🟣 Neuromuscular Re-ed
🟠 Endurance Training / Pacing
🟤 Pain Management / Desensitization
⚫ Joint Protection / Post-Surgical Precautions

“Pt trained in [strategy] to improve [specific deficit] during [functional task].”

Examples:

• “Performed sit-to-stand transfers using anterior weight shift and cueing for symmetrical LE use.”

• “Practiced gait on uneven surface with step-to gait and walker to address instability and fear of falling.”

• “Completed therapeutic step-ups with hand support to build LE strength while maintaining spinal precautions.”

[Assessment]  Patient Response to Treatment / Progress:

“Pt demonstrated [change] in [ROM, strength, balance, distance ambulated, assistance level, cueing needed, etc.].”

Examples:

• “Improved from CGA to supervision during toilet transfers with walker.”

• “Ambulated 150 ft with rollator and min verbal cues for left foot clearance.”

[Assessment] Justification for Further Treatment:

“Continued PT needed due to [risk, ongoing impairment, skill-dependent need, or progression potential].”

Examples:

• “Skilled PT necessary to progress dynamic balance and reduce fall risk during community ambulation.”

• “Patient requires skilled cueing and safety monitoring for gait training due to impaired right LE proprioception.”

• “Pt continues to require therapeutic intervention for safe reconditioning post-COVID and spinal stenosis.”

Plan for Next Visit:

“Next session will target [increased complexity, surface variability, assistive device trial, endurance, etc.].”

Examples of Strong, Skilled PT Documentation Phrases 

🟡 Gait Mechanics

Improve quality, efficiency, and safety of gait (not just distance).

• “Pt ambulated 150 ft with RW using step-to gait pattern; PT provided VC to promote left heel strike and reduce hip hiking.”

• “Gait training included figure-8 walking to address narrow BOS and poor directional control; PT monitored foot clearance and trunk alignment.”

• “Practiced narrow-based walking with AD; patient required VC to avoid foot slap and excessive lateral trunk sway.”

🔵 Balance & Fall Risk Reduction

Address sensory, motor, or cognitive systems contributing to fall risk.

• “Pt performed static balance in tandem stance with eyes closed; PT provided occasional steadying A and cueing for weight shift.”

• “Initiated perturbation training with compliant surface to improve reactive stepping responses; pt required CGA.”

• “Practiced dual-task standing (sorting objects while standing) to address attention deficits contributing to fall risk.”

🟢 Transfers & Body Mechanics

Safe/efficient movement from one surface to another using appropriate mechanics.

• “Pt practiced toilet transfers using anterior weight shift and UEs for push-off; PT cued for symmetrical LE engagement.”

• “Bed mobility retraining focused on log roll technique to maintain spinal precautions; pt required VC and environmental setup.”

• “Reinforced use of gait belt and maintained lumbar neutral during sit-to-stand; pt demonstrated reduced trunk flexion with cueing.”

🔴 Functional Strengthening

Improve strength through meaningful, task-specific movements.

• “Performed sit-to-stand drills from low surface to build quad and glute strength; patient required VC to avoid knee valgus.”

• “Patient engaged in stair climbing with handrail assist to strengthen hip/knee extensors and address endurance deficits.”

• “Completed standing theraband row exercises to improve postural endurance for grooming tasks.”

🟣 Neuromuscular Re-Education

Improve coordination, movement patterns, timing, or sensory integration.

• “Completed marching in place with auditory cueing to improve rhythm & timing of step initiation.”

• “Pt practiced weight shifting with mirror feedback to reduce L neglect and facilitate midline awareness.”

• “Engaged in targeted stepping drills with tactile cueing to retrain ankle strategy for postural control.”

🟠 Endurance Training / Pacing

Improve activity tolerance while respecting fatigue thresholds.

• “Pt completed 8-minute hallway walk with structured rest breaks; HR and RPE monitored; education provided on pacing.”

• “Trained in energy conservation techniques during prolonged grooming simulation; pt instructed in modified sequencing.”

• “Pt participated in progressive ambulation program, increasing distance by 25 ft from prior session without desaturation.”

🟤 Pain Management / Desensitization

Improve tolerance, reduce pain behaviors, and enable participation.

• “Pt instructed in diaphragmatic breathing and pacing to reduce LBP during mobility tasks; pain reduced from 7/10 to 4/10 post-task.”

• “Desensitization techniques (soft fabric brushing, joint compression) used to reduce R hand hypersensitivity; pt tolerated with mild discomfort.”

• “Pt completed low-load stretching with thermal modalities pre-session to facilitate tolerance for UE ROM activities.”

⚫ Joint Protection / Post-Surgical Precautions

Promote healing, avoid re-injury, and maintain safety during activity.

• “Pt performed bed mobility using log roll technique post-lumbar fusion; PT provided cueing to maintain spine precautions.”

• “Gait training included step-to pattern with RW while observing posterior hip precautions post-THA; no violations noted.”

• “Reinforced elbow AROM within MD-allowed range post-op distal humerus ORIF; pt demonstrated improved movement with decreased guarding.”