Physical Therapy Documentation Phrases

therapy documentation examples


If there’s one area of training that could improve in Physical Therapy school, it would be learning how to document therapy sessions effectively. Knowing appropriate Physical Therapy documentation phrases can help explain your intended treatment and justify more complex treatments such as neuromuscular re-education, therapeutic activity, and self-care.  

Physical Therapy Documentation Example Phrases

Neuromuscular Re-Ed Documentation Examples

The following examples are sample physical therapy documentation phrases to help you appropriately identify the skills involved in performing each treatment (in bold). These sample phrases may be used in the objective (observational) or assessment (interpretation and judgment) sections of your therapy documentation.

Quad set sequencing

“The patient demonstrates lack of quad muscle recruitment. Instructed the patient in co-contraction of quads to improve motor recruitment in order to achieve greater knee extension.”

Glute set sequencing with bridging

“Poor recruitment of glutes is a major factor in the patient’s lack of hip stability.  Our focus was on glute activation prior to hip extension.”

Abdominal contraction prior to squatting (timing)

“A change in sequencing of abdominal recruitment prior to squatting improved lumbar posture and reduced pain.”

Partial squatting on balance board

“The patient was challenged in achieving proper squat technique due to balance deficits.  Further progress will involve the removal of hand-hold assist.”

Single leg stance for balance

“The patient lacks balance and stability required to stand on a single leg. This task is useful for meeting goals of independent dressing.”

Serratus punches in supine or into ball

“The patient demonstrates poor scapular upward rotation with reaching.  Improving serratus activation through protraction will aid in upward rotation of scapulae.”

Access all 60 Examples in the Physical Therapy Documentation Template

therapy documentation templates

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Therapeutic Activity Documentation Examples

Ascending / Descending Stairs

“Instructed the patient on performance of stairs x5 with multiple cues to lead with the appropriate leg on descent.”

“Instructed the patient on performance of stairs x5 without upper extremity support for simulation of home environment.”

Stepping up onto a curb (3-6”)

“The patient demonstrated ability to properly perform front step up in order to navigate stairs at home.”

Reaching to Top Shelf with Weight

“The patient demonstrates poor body mechanics in lifting a 5# object to a shelf overhead.  Reinforced proper posture and provided cues for safe lifting of items overhead throughout treatment.”

Squatting with or without weight

“Provided verbal cues to correct for anterior translation of femur with squatting and to promote the appropriate body mechanics for sit- to- stand transfers and other functional activities.”

“Instructed performance of squatting with a weighted object in order to improve sit-to-stand function. “

“Educated the patient on proper performance of sit-to-stand, emphasizing body mechanics and proper alignment of knees.”

therapy documentation

Access full documentation examples for the following treatments in the Therapy Documentation Example Guide:

  • Lifting or pulling 20# resistance
  • Reaching with 2# Weight/ Lifting
  • Pinching or Gripping an Object
  • Lunging forward to bosu, dyna disc
  • Throwing
  • Pulling/Pushing
  • Gripping/ Carrying
  • Lifting weight
  • Transferring

What about Phrases for Therapeutic Exercise or Manual Therapy?

For the full 60+ therapy documentation examples, take a look at the Therapy Documentation Template below. 

documentation bundle

Tim Fraticelli DPT, MBA, CFP®

Tim Fraticelli is a Physical Therapist, Certified Financial Planner™ and founder of PTProgress.com. He loves to teach PTs and OTs ways to save time and money in and out of the clinic, especially when it comes to documentation or continuing education. Follow him on YouTube for weekly videos on ways to improve your financial health.

9 thoughts on “Physical Therapy Documentation Phrases”

  1. Pt performed static/dynamic balance training, CGA, using a compliant surface, including reaching in all planes and across midline outside of BOS to decrease fall risk, pt required vc to maintain COG within BOS to elicit ankle/hip/stepping strategies And self righting. Then put whatever you mentioned for education. Ex.: educated pt for at home safety w/ emphasis on _________to improve (I) and return to PLOF

    Please add any verbiage or things you would tweak for this note.

    Reply
  2. Ahhh sorry read that completely wrong.

    “Pt continues to disregard side rails (whatever they’re being non compliant with, cane, crutches etc.), subsequently to multiple verbal/tactile cues and education regarding safety to facilitate UE support while ascending/descending stairs to maintain SLS w/o LOB secondary to weakness, pt remains CGA until cooperative w/ SR use to increase safety and decrease risk of falls for independent mobility.” (or whatever their PLOF was)
    Not sure if this helps

    Reply

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