Create Your Physical Therapy Invoice Template for NPOs Effortlessly

Physical therapy invoice template for NPOs

in this video we'll look at the four components of a physical therapy daily note I'll also show you how I write a daily note and give you some tips on how to speed up your documentation let's go writing a physical therapy daily note is really straightforward when you use the soap note approach soap stands for subjective objective assessment and plan let's dive into each of these components and give examples of how your documentation might look in the clinic subjective okay so the subjective section covers what the patient or family member tells you sometimes you have to draw it out from them but usually they'll say something like this my arm is feeling really sore from sleeping on it last night great you just wrote the first part of the subjective line you can go into a bit more detail but if you do you should use that time and space in your note to write out how it's actually affecting their ability to perform functional tasks now don't write out every little detail they discuss if it's important or if it helps someone understand how they're restricted at home or in the community then write it down don't just write I feel good today or my arm is feeling fine bring the functional component into the subjective I usually follow up with something like oh what kind of activities seemed easier for you to perform which usually leads into them discussing a functional movement or some sort of overhead activity that is difficult or easy for them to do just don't complicate it I can usually write a sentence or two within the first five minutes of welcoming the patient into the clinic and that sums up what you need to know with the subjective so make it straightforward simple and to the point objective the next section is the objective section this includes all of your measurements your vital signs your treatments your procedures and your special tests that you perform in a daily note this will generally include your vital signs and the exercises and treatments you perform during the session now here's where the note can get a little long some clinics use a flow sheet to track the exercises and treatments which I prefer other clinics require you to write out each activity or exercise that you do regardless of the method you need to be specific to include repetitions resistance assistance equipment direction or cueing that's required and other identifiers to help someone else who may be treating the patient next time this video is brought to you by the therapy documentation templates from PT progress the average therapist spends 1 to 2 hours a day documentation it's the number one complaint of being a therapist by the end of the day your brain is tired and it's difficult to put into words the skilled treatment you've been performing the entire day when I finally learn how to document correctly it saved me about 30 to 60 minutes a day these well-crafted documentation phrases save you time by providing you with inspiration on how to phrase the skill that you provide to your patients the guides have over 60 actual examples from assessments goals and even home health documentation templates so head on over to PT progress comm slash documentation to download the templates and to save you time and mental energy so you can reclaim your evenings okay we're on to the third section of your note the assessment every note needs an assessment a good assessment will relay what skill you provided and why you are even needed don't just write the patient tolerated the treatment well that's a horrible assessment a better approach is to comment on the impairments you've identified during the session the response or change you noted with your Corrections and how you advance the patient further towards achieving their goals also you remember those functional tasks we identified in this objective section it's a really good place to relate them back into your treatment here in the assessment here's an example the patient demonstrated poor coordination with ascending stairs putting him at a greater risk for Falls at home verbal cueing to emphasize increased hip flexion allowed the patient to clear his foot completely to avoid catching on the step now the fourth section to consider is the plan what are the next steps with the patient is someone else seeing them what should they know this section is so important because sometimes you might not see the patient for another week it's your job here to write out helpful one to two-sentence plan to identify other exercises or approaches that you want to take to progress the patient or for the other person like a therapist assistant to progress the patient here's an example trial a single leg dynamic balance task on the arocs pad or provide the patient with green thera-band to progress with hip abductor strengthening with lateral stepping exercise if you're interested in more documentation examples head on over to PT progress comm where you'll find my personal and documentation templates I put these templates together as a way to say myself time but now hundreds of therapists are using these templates to write better notes every day so now you know how to write a daily note in future videos we'll cover ways to write progress notes evaluations and discharge notes until then if you like this video I'd love it if you liked it below and be sure to subscribe to the channel and we'll see you in the next video