If you’re new to physical therapy, you may be wondering how to write good physical therapy documentation. Maybe you’re not confident in your writing skills, and you worry you’ll either produce sub-par documentation or spend more time working with words than with people.
Or, maybe you’re a seasoned therapist who is tired of churning out the same phrases over and over again. You know how to write adequate documentation, but you’re looking to go further and create notes people want to read.
Just like in PT, strong writing skills take time to build and balance. In this article, we’ll go over three different areas you can target to improve your documentation: clarity, intention, and variety.
Clarity in sentence structure: “Who did what?”
Writing is an isolated activity; it’s communication from a person in one time and place to (often) unknown persons in distinctly different times and places. Without shared context, vague words can be easily misinterpreted or misread. As you document what happened in the clinic, try to imagine how the sentence would read to someone who wasn’t there. The way you structure your sentence will facilitate clear, accurate reading.
The most essential principle to remember in your documentation phrases is clarity: who did what, and when did it happen? Don’t make the reader guess these key details.
That being said, you don’t need to be lengthy or pedantic in your description of the events. Although you’re not writing to yourself, you’re also not writing to the general public; the reader should be familiar with documentation phrases and know the proper assumptions to make.
Indicate changes in subject
Overall, it’s implied that the subject of the sentence is you, the therapist. Grammatically, you’re the “subject.” For instance, in the sentence “Provided cues for proper sit-to-stand technique,” the reader assumes that the therapist is the one who provided the cues.
However, if the sentence involves more than one person, you should indicate the patient’s role: “Instructed the patient to keep knees apart when rising from a chair.”
Or, try wording it with the patient as the subject of the sentence:
“The patient was instructed to keep knees apart when rising from a chair.”
The reader assumes that “the patient was instructed by the therapist,” so you don’t need to write it.
Consider one ambiguous example:
“The patient demonstrates poor body mechanics in lifting a 5# object to a shelf overhead. Reinforced proper posture with verbal cues and lifted items safely overhead.”
At issue is the second sentence. Halfway through, the subject switches from the therapist to the patient (the therapist “reinforced proper posture” but the patient “lifted items safely”).
You can clarify this sentence in one of a few ways, depending on what actually happened:
No outcome: “Reinforced proper posture and provided verbal cues for safe overhead lifting.”
Successful outcome: “Reinforcing proper posture with verbal cueing helped the patient lift items safely overhead.”
Ongoing outcome: “Reinforcing proper posture and providing verbal cues help the patient lift items safely overhead.”
Watch your Verbs
The subject of your sentence is important, but so is the verb or predicate (that which follows). If your sentence doesn’t have a strong subject/predicate relationship, its meaning will be unclear, even to experienced documentation readers.
Consider this example:
“Providing verbal cues to correct for anterior translation of femur with squatting to promote the appropriate body mechanics for sit-to-stand transfers and other functional activities.”
This sentence has no subject, but we know the subject is the therapist. That isn’t the problem.
The main problem is that the sentence has no clear predicate. The first action word, “Providing,” is technically a noun, so the reader expects an eventual predicate to come on the scene: “Providing verbal cues to correct…..to promote…for transfers and activities…” did what? What did all that verbal-cue-providing accomplish?
To answer that question, you could say, “Providing verbal cues to correct for anterior translation of femur with squatting to promote the appropriate body mechanics for sit to stand transfers and other functional activities was successful.” But really, this sentence is too “front-loaded”; it takes too long for the reader to get through the introductory material.
Instead, to improve this sentence, just change the beginning into a subject||predicate – or a predicate with the therapist as the assumed subject:
“|| Provided verbal cues to correct for anterior translation of femur with squatting. This treatment || promotes the appropriate body mechanics for sit-to-stand transfers and other functional activities.”
As a bonus, I divided the sentence in two, separating the treatment description (what was corrected) from the application (what that promotes), an intentionality phrase we’ll cover later.
Tense: “When did it happen?”
As you write your daily notes or therapy evaluations, you may fluctuate between past, present, and future tense – the information that tells the reader when something happened. It’s fine to fluctuate; just be intentional with your choice and consistent throughout all related scenarios.
To establish good grammatical tension in your notes, first identify whether the action you’re documenting is ongoing, done and gone, or anticipatory. Another way to think about it is the purpose your documentation serves: does it describe, report, or project?
Describing the present
Therapists often use present tense to document the patient’s diagnosis, reasons for therapy, ongoing impairments, and treatment goals.
“The patient is a 45-year-old female who presents with symptoms of low back pain. Her goal is to return to work as a forklift operator as soon as possible.”
“The patient is tender to palpation along the right supraspinatus tendon with active resistance.“
Reporting the past
A large portion of your documentation will be of a reporting nature. Use past tense to explain what was done and how it was done: how the patient performed and how you instructed.
“The patient demonstrated poor body mechanics in lifting 5# object to shelf overhead. Reinforced proper posture and provided cues for safe lifting of items overhead throughout treatment.”
Projecting the future
Use future tense to indicate what the patient will be working on for the remainder of therapy and what you will be considering as their treatments progress.
“Future treatment will focus on further stabilization exercises in standing to promote proximal hip stability during single leg stance.”
Again, it’s okay to fluctuate tense so long as you’re consistent and intentional. When describing an ongoing problem, use present tense. If you’re reporting an already-executed exercise, instruction, or test, use past tense. And if you’re projecting a result, use future tense.
Modifying phrases: “How?”
Many times, a sentence requires more information than just the subject and verb. In such cases, you’ll use what we call “modifiers,” to elaborate “how” an action or instruction was performed: such as “with X,” “because of X” “to do X.”
If you’re not careful, this information can overload your sentence and cause wordiness, a malady common in technical writing. Sentences are wordy when they contain too many tacked-on phrases, leaving the reader wondering, “Wait, what did I just read?
Balance your sentence structure
You can best manage your modifying phrases when you know how they relate to the structure of your sentence.
Consider the two sentences in the following example:
“The patient required verbal cueing for proper sequencing when ambulating with a straight cane. After practicing for ten minutes throughout the clinic on various surfaces, the patient demonstrated independence with the device.”
Take a look at the first sentence. Here’s the basic structure:
The subject is “the patient,” the verb is “required,” and what they required was “verbal cueing.”
Now for the modifiers:
What kind of verbal cueing? “For proper sequencing.” What kind of sequencing? “when ambulating.” What kind of ambulating? “with a straight cane.”
I like to use parentheses to visualize the modifiers. For this sentence, it would look like this:
The patient || required | verbal cueing (for proper sequencing (when ambulating (with a straight cane))).
The more parentheses we add, the more modified the sentence becomes.
For the second sentence, the subject is “the patient,” the action is “demonstrated,” and what they demonstrated was “independence.”
What kind of independence? “With the device.” When? “after practicing” What kind of practicing? “for 10 minutes” “throughout the clinic” “on various surfaces”
This is how the sentence looks with embedded parentheses:
(after practicing (for 10 minutes) (throughout the clinic) (on various surfaces)) the patient demonstrated | independence (with the device).
These sentences look complicated when dissected like this. However, they read well because the writer has structured them appropriately. The first sentence has several modifiers following the predicate, but they increase in specificity like nesting dolls.
The second sentence is “front-loaded” with a long introductory phrase, but the phrase isn’t nesting and the reader isn’t bogged down before they arrive at the subject and predicate.
What you don’t want to do is to tack phrases haphazardly to the sentence or clutter the subject and predicate. The example sentences become less intelligible when written this way:
“The patient, for proper sequencing when ambulating with a straight cane, required verbal cueing.”
“On various surfaces throughout the clinic after practicing for 10 minutes with the device, the patient demonstrated independence.”
All the same words and meaning, but the sentences are vaguer and more difficult to read.
2. Intention: “Why?”
You’ll use modifying phrases to explain not only “how” the treatment was done, but also “why” it was done. Documenting your “why” or intention impacts the readability of your writing as well as the amount of money insurance companies will pay for the treatment.
How so? It comes down to coding. For treatment categories such as therapeutic activity, therapeutic exercise, and neuromuscular re-education, you’ll have flexibility in determining which exercises belong in what category. Your intention for the treatment will inform how it is coded.
Here’s a breakdown of each category’s treatment intention:
- Therapeutic exercise addresses a specific, physical parameter that limits function, such as muscle weakness, diminished range of motion or decreased flexibility.
“Instructed patient to perform squatting with weighted object in order to improve sit-to-stand function.”
- Neuromuscular Re-education prepares patient for therapeutic activities by targeting stability, balance, coordination, posture, proprioception, and muscle recruitment and facilitation.
“The patient lacked proper timing of scapulothoracic stabilizers with lifting tasks. Instruction of proper sequencing improved performance and reduced pain.
- Therapeutic Activity trains proper body mechanics for the performance of a specific task to rehabilitate activities of daily living.
“The patient demonstrated ability to lunge forward safely with multiple attempts, a task required to reach low cabinets at home.”
You can read more about the importance of intention in another post. In this article, let’s focus on ways to justify intention seamlessly in your documentation.
Writing with Intention
Don’t just narrate the session. As the writer, you have the power to interpret what happened and why it happened. And it’s not spinning yarns; you’ll communicate truthfully why an exercise was selected and what the performance of it means for the patient.
Consider the following statement:
“The patient performed squatting exercises with difficulty.”
This sentence is easy to read, but it doesn’t say much about why the exercise was difficult for the patient or what purpose it plays in their overall plan of care. Don’t make the reader have to guess – especially when that reader is an insurance auditor.
As you write your documentation, you can convey your intention with the following phrases:
Patient did X treatment…
- in order to improve X function.
- because X strength/ability is required for X activity/goal.
- to simulate X physical requirement for X specific task.
These examples aren’t meant to be formulae; in fact, sticking your own words into these sentences might make them clumsy and unnatural. If including your intention makes the sentence too long and wordy, you can divide the sentence in two or join two related sentences with a semicolon.
Consider these examples:
“The patient performed overhead reaching activities with various weights; continued progression of weight is required for safely handling household items.”
“Performance of stairs x5 was executed without upper extremity support to simulate safe navigation of steps into home environment.”
Or, the example from earlier in this article, with two sentences:
“Provided verbal cues to correct for anterior translation of femur with squatting. This treatment promotes the appropriate body mechanics for sit-to-stand transfers and other functional activities.”
Incorporating intention in your writing will give your sentences focus. Not only will you be recounting sequential actions in a clinic; rather, you’ll be telling a micro-story of what happened, how it happened, and why that’s important for the patient’s plan of care.
3. Variety: The spice of SOAP notes
Once you have your sentence structure down pat and your intention clearly conveyed, you may think you’ve mastered all you need to write good therapy documentation. While that may be true, changing things up every now and then will help keep your writing skills pliable and your boredom at bay.
You’ll be writing thousands of therapy documentation phrases each month. It’s bound to get repetitive. For your own engagement, get creative in your documentation – only be careful not to experiment at the expense of clarity.
Vary the subject
When writing assessment phrases, you may find yourself in a rut of beginning each sentence with “the patient Xed.” This is the usually clearest way to start a sentence, but it does get dull over time. You can experiment by placing your instruction at the start of the sentence; after all, the patient demonstrated what you told them to do. Or, you can focus on the treatment and its effect on the patient rather than on the patient’s action.
Here are a few examples of alternating subjects:
- Patient as subject: “The patient performed stairs 5x and required multiple cues to lead with appropriate leg on descent.”
- Therapist as subject: “Instructed patient to perform stairs 5x; provided multiple cues to lead with appropriate leg on descent.”
- Treatment as subject: “Ambulation with straight cane required verbal cueing for proper sequencing.”
- Instruction as subject: “Multiple cueing was required for the patient to stay close to the walker.”
Although the patient is always the topic of your documentation, they need not be the subject of every sentence.
Use passive tense sparingly
Grammar software sounds the alarm whenever passive construction is used, but it’s not always bad to include passivity in a sentence. In fact, I just did: “whenever passive construction is used” is passive. I could have rewritten the sentence “Most grammar software sounds the alarm whenever you use passive construction,” but it actually works better in passive tense by deemphasizing the implied subject.
So how will this rhetoric trick help your documentation writing?
It’s generally better to keep sentences active, but you can try incorporating sentences with passive construction to create variety. As a rule of thumb, use active construction for sentences that convey action (your instructing or the patient’s performing/demonstrating). But if the sentence describes or reports passive change or status (requirements, improvements, etc.), try the passive construction. Revert the sentence to active if it’s unclear what’s happening to what.
The best occasions for passive construction are when the verbs are themselves passive:
- “X function was improved by X treatment.” (Instead of “X treatment improved X function”)
- “X strength was increased by X exercise.” (Instead of X exercise increased X strength.”)
Passive construction gets clumsy when the sentence has a subject, action verb, and an object: “The patient lifted 10# weight overhead with ease” as opposed to “10# weight was lifted overhead with ease by the patient.”
It gets worse with modified sentences. Consider this sentence in active construction:
“The patient demonstrated improved ability to move through the existing range of motion without increased pain.”
Now the same sentence in passive construction:
“Improved ability to move through the existing range of motion without increased pain was demonstrated by the patient.”
Not only is the sentence structure now inside out, the reader needs to wade through a sea of modifying phrases to get to the main action of the sentence, the subject|predicate.
Rather than turn active sentences passive for variety’s sake, try switching your “point of view,” or changing the subject as detailed above.
- Instead of writing, “the patient performed X exercise,” try writing, “Instructed patient to perform X exercise.”
- Instead of writing, “the patient demonstrated X function,” try “Exercise helped patient to attain X function.”
Lead with a modifying phrase
Another easy way to vary an overly-familiar sentence structure is to place a short, generic modifier to the beginning of the sentence. Here’s that example sentence again:
“The patient demonstrated improved ability to move through the existing range of motion without increased pain.”
You can take the final modifier, “without increased pain,” and have it introduce the whole sequence:
“Without increased pain, the patient moved through the existing range of motion with marked improvement.”
This introductory modifier applies to the whole sentence, and not one specific part.
Or consider this ambiguous sentence:
“The patient demonstrated ability to properly perform front step-up in order to navigate stairs at home with minimal verbal cueing.”
The final modifier, “with minimal verbal cueing” is misplaced, modifying “to navigate stairs at home” instead of “to properly perform front step-up.” Moving this modifier to the beginning of the sentence brings it closer to the action and adds some variety to the sentence order:
“With minimal cueing, the patient demonstrated ability to properly perform front step-up in order to navigate stairs at home.”
You’ll also notice this sentence has an explicit intention: “in order to…” You could place this intention phrase at the beginning of your sentence:
“In order to navigate stairs at home, the patient properly performed front step-ups with minimal cueing.”
I eliminated the phrase “demonstrated the ability to” and made “perform” the past-tense verb here to reduce wordiness. Which brings us to some final thoughts…
Remove unnecessary words
It takes more time to write efficiently than it does to write inefficiently; however, it takes more time to read and understand inefficient writing than efficient writing. Your documentation isn’t a college-level English paper, so don’t feel you need to obsess over conciseness and coherence. However, it’s important to consider the reader and eliminate needless words that only bog them down.
As exemplified above, “demonstrated the ability to X” can easily be reduced to “Xed,” unless the ability to do X is more important than the action (for instance, when emphasizing a treatment for therapeutic activity coding instead of for therapeutic exercise coding).
Here’s another wordy sentence:
“Performance of weight shifting was helpful in allowing the patient to slow down and concentrate on his performance.”
Without altering its meaning, I can replace “was helpful in allowing the patient to” with “helped the patient.” Like this:
“Performance of weight shifting helped the patient slow down and concentrate on his performance.”
This switch not only reduces the number of words in the sentence, it puts the predicate in active voice: “helped” instead of “was helpful.”
As you write your documentation, consider how your sentences will read to someone removed from your treatment process. Make sure you write clearly, definitively, and descriptively, capturing the intention of your treatment and incorporating the patient’s response to treatment. Use your words to journalistically depict what happened in the clinic and why it matters to you, to the patient, and to their insurance provider. And don’t get bogged down. There are innumerable ways to reword documentation sentences to spark creativity and prevent boredom.
If you’d like more help writing documentation for specific notes, or if you need more examples of assessment phrases, download a comprehensive documentation bundle here!
This article was written by Naomi Benecasa, a cellist with a Bachelor’s in Music Performance and a Master’s in Music Psychology. Fascinated by fitness and fermentation, she provides copywriting and editing services for PTProgress from her home in New York.