Maintenance Physical Therapy Documentation Examples Inspired by the CMS Manual

Maintenance Physical Therapy Documentation Examples Inspired by the CMS Manual

Maintenance Physical Therapy Documentation Examples Inspired by the CMS Manual

This post on Maintenance Physical Therapy Documentation Example is only but a small portion (although very helpful) of what is required for your medicare physical therapy note. For a complete note, be sure to include ALL necessary steps to satisfy requirements as seen in the CMS manual at

Demystifying Maintenance Physical Therapy Documentation

Physical therapy plays a pivotal role in sustaining individuals’ functional capacities, particularly those grappling with chronic ailments or in the post-injury phase. Maintenance physical therapy, which zeroes in on conserving a patient’s existing condition and curbing further deterioration, stands out as an essential facet of this care. For physical therapists rendering these services to Medicare beneficiaries, impeccable documentation is paramount. This safeguards alignment with Medicare’s stipulations and crucially showcases the medical relevance of the maintenance therapy, validating the coverage of the services provided.

Key Facets to Embed in Maintenance Physical Therapy Documentation

To present a holistic record of the provided maintenance physical therapy and substantiate its medical relevance for Medicare, documentation must encapsulate several core elements:

  1. Patient’s Clinical and Functional Overview: Detail the patient’s health condition, including diagnosis specifics, symptomatology, and the gravity of the ailment. Also, sketch out their functional status, spotlighting any operational constraints or impairments.
  2. Tailored Clinical Evaluation: This individualized probe of the patient’s health condition underpins the rationale behind the medical relevance of the therapeutic services.
  3. Chalking Out a Maintenance Regime: When a therapist’s expertise is pivotal in crafting a maintenance routine, the documentation should vividly portray this program’s conceptualization and the logic behind chosen interventions.
  4. Guidance on the Maintenance Regime: Elucidate on the tailored advice given to the patient or their caregiver regarding the execution of the maintenance regime and their proficiency in adhering to it.
  5. Scheduled Reassessments: Document any periodic re-evaluations or subsequent assessments essential for the maintenance program, encompassing the findings and any program tweaks ensuing from them.

Documentation Pitfalls and How to Dodge Them

While grasping the crux of documentation is vital, awareness of frequent pitfalls can uplift the documentation’s efficacy. Here are some areas to tread cautiously:

  1. Generic Descriptions: Dive deep into specifics, offering a lucid view of the patient’s situation, services, and the logic behind those services. We’re dodging vague, over-the-horizon descriptions here!
  2. Overlooking Medical Relevance: It’s imperative to lucidly pen down the medical relevance of the rendered services and the rationale for necessitating a skilled therapist. No stone unturned in showcasing medical necessity!
  3. Sketchy Records: All nuances of the maintenance physical therapy must be documented coherently, from the program’s inception, guidance, to any subsequent evaluations. Leaving out details? Not on our watch!
  4. Stagnant Documentation: Refresh documentation in tandem with the patient’s evolving condition, program alterations, or fresh insights from subsequent evaluations. Our records are as dynamic as our therapy sessions!

Maintenance Physical Therapy Patient Examples

At minimum, your documentation should include the elements and essence of what is seen below. Keep in mind, this is not all you will need for your documentation. You need a complete, compliant note. Check out this blog post (click here) to check out the Medicare Documentation Cheat Sheet that I like to refer to (the link is at the end of this post as well so you can check it out afterwards).

Patient Example 1: Mrs. Smith’s Osteoarthritis of the Knee Maintenance Plan

Patient’s Medical Condition and Functional Status: “Mrs. Smith, a 68-year-old female, diagnosed with Osteoarthritis of the Knee, reports persistent knee pain, especially after ambulation for more than 5 minutes. No history of falls, but a noticeable limp is evident in her gait due to knee discomfort. Morning stiffness improves post stretching, however, stair navigation and squatting activities pose significant challenges.”

Individualized Assessment: “Upon clinical examination, Mrs. Smith exhibited limited knee range of motion, especially during flexion and extension, as well as reduced functional mobility. Based on the presentation and clinical findings, maintenance therapy is deemed medically necessary to manage symptoms and prevent further decline.”

Establishment or Design of a Maintenance Program: “A specialized program has been designed for Mrs. Smith to address knee stabilization, flexibility training, and pain management strategies. This program encompasses targeted exercises, posture corrections, and ergonomic advice tailored to her needs.”

Instruction on the Maintenance Program: “Mrs. Smith was instructed in a home exercise regimen emphasizing knee support and strengthening. Demonstrations were provided, and she was observed for technique, ensuring correct form. Her ability to replicate the exercises was verified, and written instructions, along with pictorial representations, were provided for reference.”

Periodic Reevaluations or Reassessments: “A structured re-evaluation plan has been set, wherein Mrs. Smith will return to the clinic every 4 weeks for progress tracking and necessary adjustments to her program based on her evolving needs.”

Patient Example 2: Mr. Johnson’s Post Cardiac Surgery Maintenance Update

Patient’s Medical Condition and Functional Status: “Mr. Johnson, a 72-year-old male, has a medical history significant for cardiac surgery 6 months ago. He’s made improvements in his cardiovascular endurance but still encounters shortness of breath during brisk walking.”

Individualized Assessment: “Mr. Johnson demonstrated improvements in objective cardiovascular endurance measures compared to the initial assessment. However, rapid movements and intense activities still pose a challenge. Maintenance therapy, focusing on endurance training and aerobic capacity, remains vital for his overall health and well-being.”

Establishment or Design of a Maintenance Program: “A program has been customized for Mr. Johnson that emphasizes aerobic training exercises and functional endurance activities. This plan will address his unique challenges and aid in improving his cardiovascular health.”

Instruction on the Maintenance Program: “Mr. Johnson has been coached on graded aerobic exercises and techniques to enhance cardiovascular function. He was able to demonstrate a sound understanding and execution of the prescribed exercises. An illustrated guide was provided for home reference.”

Periodic Reevaluations or Reassessments: “A bi-weekly check-in has been scheduled for Mr. Johnson over the next two months. These sessions will monitor his progress, reassess his functional capabilities, and tweak the program as required to ensure maximal benefits.”

Relevant Readings

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The Best Medicare Note Ever?

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General Disclaimer

Please be advised that the information provided in these blogs is based on my professional experience as a Doctor of Physical Therapy and does not constitute legal, insurance compliance, billing, or federal agency expertise advice. While I strive to provide accurate and up-to-date information, the accuracy and applicability of the content are subject to change and should not be relied upon as definitive expert guidance. Always consult with a qualified professional in the relevant field to ensure compliance and accurate advice tailored to your specific situation before making any decisions or implementing any advice.

Dr. Grayson Starbuck, DPT, CSCS, FAAOMPT

Dr. Grayson Starbuck, DPT, CSCS, FAAOMPT

Dr. Starbuck is a seasoned professional with a versatile background spanning physical therapy, content creation, business consulting, and motor vehicle accident/personal injury care.