Physical therapy forms should cover the following aspects of patient-client management: initial examination/evaluation, visit, re-examination and discharge.
Every visit by a patient should be supported by the relevant physical therapy forms. The patient’s full name and identification number should be documented on every form. All physical therapy forms related to examination, evaluation, visits and discharge must be authenticated by the physical therapist who provided the service. The forms should clearly indicate if the patient came through a referring doctor or just came for a visit directly. All physical therapy forms should mention the referral source through whom the patient was sent for the visit.
Initial examination or evaluation forms should include the following data: general demographics, social history, employment details, growth and development, living environment, general health status, health and social habits, family history, medical or surgical history, main complaints at present, current medications, and other clinical tests.
Forms related to visits should ask the patient for the following information: self-report by the patient, changes in patient condition and response to interventions.
Discharge forms should contain the patient’s current physical status, degree of improvement, and referrals for additional services.
Typically, most physical therapists ask their patients to fill out forms depending on the kind of insurance they are covered under and the type of injury. If the therapy is covered under ‘No Fault Insurance’, the patient will need to fill in a patient information form, appointment policy form, financial policy form, Assignment of Benefits form, history form and an authorization form.
There are a number of forms that need to be accomplished every time a patient comes in for a visit. Managing the paperwork aside from the other aspects of the private practice can be a handful at times yet we as physical therapists need to stay compliant. Which is why a good number of practices are utilizing physical therapy emr systems to help in managing all the documents.
A Physical therapy software can be configured to assist the staff in determining patients that would require additional forms or documentation specific to their type of coverage.
If the patient is covered under workman’s compensation, a patient would be required to fill in a patient information form, appointment policy, history and authorization.
For a patient not covered by any of these insurance covers, the following forms would need to be filled out: patient information, health survey, health questions, financial policy, appointment policy, history and authorization.