I think we are all aware that “tolerated well” is commonly written in the assessment portion of physical therapy notes and I really don’t know what it means.
- Does it mean the patient didn’t die?
- Does it mean the patient felt better?
- Does it mean the patient didn’t break a sweat?
- Does it mean the patient was status quo?
In school, I was taught never to write the phrase “tolerated well” and I can honestly say that after 10 years of treating patients, I still have never written it. Actually I was taught don’t ever become this type of therapist:
S: no new complaints
O: see flow sheet
A: tolerated well
I think we all know therapists who document like that. And if you’re one of them, are you proud of that!?
So I guess this is my cry to PT’s to take their documentation up a level (maybe even a few levels for some people) and don’t get lazy. I’m not saying I write the greatest notes in the world or that I haven’t gotten lazy at times, but overall I have been told I’m a thorough documenter and there are many reasons why you should be too.
The most obvious reason to document well is you’re probably going to have a hard time remembering exactly how a patient felt, moved, or what they/you did during the treatment. And if that’s the case, you won’t be able to progress the patient accordingly and you’ll be doing the patient a disservice.
Another important reason to improve your documentation is we all know that insurance companies are looking for any reason not to have to pay us for our services. And if your documentation can’t support what you did or continued PT, you will have a hard time convincing an insurance company to pay you and/or give you more visits – hell, it’s hard even when you have good documentation.
Personally, the reason that I say over in my head that usually stops me from getting lazy is what if this patient sues me – can I prove/justify my side of the story. I feel like this alone should be enough to make you be more thorough with your documentation.
Obviously the best assessments are a description of the “why” – why does your patient have pain, why are they feeling better/worse, why does a patient have trouble or improvement doing a certain activity, why does a patient move a certain way, why are you doing the type of treatment you’re doing, etc.
I know that sometimes assessments can be difficult to write (usually I struggle with the post-op patients who have been coming for a couple months and are plugging along with no crazy change in functioning/impairments), so here are a few general statements that you can add more detail to accordingly:
- Patient progressing well and will continue to benefit from physical therapy.
- Patient progressing well as evidenced by…..(add in an objective measurement or a functional improvement, etc.)
- Patient will continue to benefit from physical therapy to improve….(list deficits, functional limitations, etc.)
If you truly have no idea what to write, maybe that patient shouldn’t be coming to PT anymore.
Let me know what phrases you like to write or your experience(s) with insurance companies in regards to documentation.
And I didn’t even talk about goals being measurable, functional, and timed……
- Dennis Treubig, DPT
- Dennis Treubig, DPT
Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!
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