What are the most common entries in communication for physical therapy documentation?

Common Entries in Physical Therapy Communication Documentation

The most common communication entries in physical therapy documentation include patient education and advice provided, discussion of treatment plans and goals, coordination with other healthcare providers, and documentation of patient responses and concerns during the encounter. 1

Primary Communication Documentation Categories

Patient-Provider Verbal Exchanges

• History and background information represents a substantial portion of documented communication, with physical therapists spending approximately 49.5% of encounter time speaking while patients contribute 33.1% 2
• Advice and suggestions regarding physical activity type, frequency, and home exercise programs are consistently documented communication elements 3, 2
• Patient concerns and questions should be documented using the patient's own words when capturing symptoms or specific complaints 4

Treatment-Related Communication

• Exercise prescription communication to both patients and referring healthcare providers is a standard documentation entry 1
• Progress updates and goal discussions with patients about their functional improvements and treatment modifications 1
• Barriers and facilitators to treatment adherence, including physical limitations, motivation levels, and available support systems 3

Interprofessional Communication

• Notifications to healthcare providers when patient status changes or when specific thresholds are met (such as abnormal findings or lack of progress) 1
• Referral communications and coordination with other healthcare team members 1
• Documentation of collaborative decision-making regarding pharmacy choices, treatment modifications, or additional services needed 1

Documentation Methods and Tools

Structured Documentation Approaches

• Templates and standardized forms are commonly used for documenting routine communication elements, though they should accurately reflect the actual encounter 1, 5
• Drop-down boxes and macros facilitate efficient documentation of standard communication elements like patient education topics covered 1
• Written communications including reports and charts represent 23% of assessed communication methods in physical therapy programs 6

Real-Time Documentation Practices

• Verbalizing actions while documenting helps maintain patient engagement—physical therapists should explain what they are typing or looking for in the record 1
• Sharing screen content with patients when discussing their progress, test results, or treatment plans 1
• Separating typing from patient interaction by conducting brief documentation sessions while maintaining primary focus on the patient during conversation 1

Emotional and Psychosocial Communication

• Emotional content is documented but represents a small portion of encounters (providers 1.4%, patients 0.9% of encounter time) 2
• Rapport-building exchanges at the beginning of encounters, including greetings and establishing comfort 1, 3
• Psychosocial factors affecting treatment, including stressors, life events, and impact on daily activities 4

Common Documentation Pitfalls to Avoid

• Excessive copy/paste creates repetitive entries that may not accurately reflect the current encounter and can be flagged as inappropriate documentation 1
• Overly verbose notes generated by templates that satisfy coding requirements but fail to communicate clinically relevant information 1
• Neglecting to document patient's actual words when describing symptoms or concerns, which loses important clinical context 4
• Interrupting patients during communication—more experienced clinicians show higher rates (7.6%) compared to less experienced staff (2.6%), which should be avoided 2

Best Practices for Communication Documentation

• Document concisely while capturing the essential information exchanged, thought processes, and decisions made 5
• Maintain body orientation toward the patient while documenting to preserve engagement 1, 4
• Explain computer use to patients, verbalizing what you are documenting and why 1
• Review documentation with the patient after completing entries to ensure accuracy and shared understanding 1