Complete Physical Therapy Documentation System

Save hundreds of hours and elevate your clinical practice with a complete, compliance-ready documentation system designed for Physical Therapists in the United States. Includes 400+ professionally structured, fully editable templates to support patient care, clinical documentation, practice management, and regulatory compliance — all ready for immediate implementation.

Who This System Is Designed For

The Complete Physical Therapy Documentation System – USA Edition is designed for licensed Physical Therapists and Physical Therapy clinics at different stages of practice.

If you are looking to streamline documentation, improve consistency, reduce risk, and elevate the overall quality of patient care, this system was built for you.

Ideal for: Physical Therapists in private practice Clinic owners and group practices Home health and outpatient settings PTs seeking structured, professional, and scalable documentation

Licensed Physical Therapists

Designed for licensed Physical Therapists working in:

  • Private practices

  • Outpatient clinics

  • Home health and private-pay settings

This system provides professionally structured, standardized documentation to support consistent patient care, clinical accuracy, and compliant practice workflows.

Physical Therapy Clinics & Rehabilitation Centers

Designed for physical therapy clinics, rehabilitation centers, and multi-provider practices looking to:

  • Standardize documentation across providers

  • Align clinical workflows and internal protocols

  • Improve the quality and consistency of patient-facing documentation

  • Support scalable, well-organized practice operations

Home Health Physical Therapists

Designed for Physical Therapists providing home health or in-home care services who need:

  • Efficient, easy-to-use documentation

  • Structured templates that support care delivered outside the clinic

  • Organized records for consistent follow-up and reporting

Built to help clinicians document accurately and efficiently — even in mobile or time-restricted environments.

Hospital-Based Physical Therapists

Designed for Physical Therapists working in hospital and acute care settings who require:

  • Accurate and structured clinical evaluations

  • Clear, consistent progress documentation

  • Well-organized clinical reports to support interdisciplinary care

Built to support precision, clarity, and professional documentation standards in complex clinical environments.


(Templates may be adapted to support internal hospital documentation requirements.)

Rehabilitation-Focused Physical Therapists

Ideal for Physical Therapists working in rehabilitation settings who need structured tools to support:

  • Functional performance tracking

  • Objective progress monitoring over time

  • Rehabilitation-specific treatment protocols and plans of care

Designed to help clinicians document outcomes clearly, track patient progress, and support evidence-informed rehabilitation workflows.

Early-Career Physical Therapists

Suitable for recently licensed Physical Therapists who are transitioning into clinical practice and want to:

  • Develop consistent documentation habits

  • Learn professional documentation standards used in real-world settings

  • Build confidence through structured, ready-to-use templates

Designed to support clinicians early in their professional practice, without compromising professional standards.

Clinics Seeking Documentation Standardization

Designed for growing physical therapy clinics and multi-provider teams that need to:

  • Align all clinicians under a single documentation standard

  • Ensure consistency across evaluations, progress notes, and plans of care

  • Maintain professional and organized records at scale

Built to support team-wide alignment, operational consistency, and scalable clinical workflows.

Key Benefits of the Complete Physical Therapy Documentation System

Immediate Time Savings

Stop building documentation from scratch. Use professionally structured templates to streamline evaluations, progress notes, and clinical reports, allowing you to focus more on patient care and less on paperwork.

Professional Documentation Standardization

Establish a clear, consistent documentation standard across all patients and providers, helping elevate the quality, clarity, and reliability of your clinical records.

Fully Editable & Customizable Templates

All templates are 100% editable, allowing you to adapt documentation to your practice setting, specialty, or clinic requirements — without rigid limitations or locked formats.

Clearer Patient Communication & Engagement

Well-structured reports and patient-facing documentation help improve understanding, set expectations, and build trust, strengthening the therapeutic relationship and overall care experience.

Reduced Documentation Errors & Omissions

Comprehensive, professionally designed templates help minimize gaps, inconsistencies, and missing information, supporting more accurate and defensible clinical records.

Alignment with Professional & Compliance Best Practices

Includes essential ethical, administrative, and compliance-aware documentation designed to support professional standards and help reduce risk for both clinicians and patients.

This system is built to support efficiency, consistency, and professional documentation standards — without unnecessary complexity.

What’s Included in the Complete Physical Therapy Documentation System:

TOPIC 1 — INITIAL INTAKE, PT EVALUATION & SCREENING

Essential forms to start care with clarity, consistency, and professional documentation standards.

  • ✅Patient Intake Form (Medical History)
  • ✅Comprehensive Physical Therapy Evaluation
  • ✅General Assessment Form
  • ✅Postural Assessment
  • ✅Global Postural Assessment
  • ✅Functional Assessment
  • ✅Musculoskeletal Evaluation
  • ✅Spine Evaluation (Cervical/Thoracic/Lumbar)
  • ✅Hip Evaluation
  • ✅Knee Evaluation
  • ✅Ankle & Foot Evaluation
  • ✅Hand & Wrist Evaluation
  • ✅Elbow Evaluation
  • ✅Shoulder Evaluation
  • ✅Cardiopulmonary Assessment
  • ✅Acute Care / ICU PT Evaluation
  • ✅Lymphedema Assessment
  • ✅Amputation / Residual Limb (Stump) Assessment
  • ✅Facial / TMJ-Related Assessment
  • ✅Neurological Evaluation
  • ✅Pediatric Neuro Evaluation
  • ✅Pediatric PT Evaluation
  • ✅Integumentary / Dermatologic Functional Assessment
  • ✅Pelvic Health / Women’s Health Assessment
  • ✅Women’s Health PT Evaluation
  • ✅Geriatric Evaluation
  • ✅Gerontology-Focused Assessment
  • ✅Orthopedic Evaluation
  • ✅Rheumatology / Arthritis-Focused Assessment
  • ✅Clinical Pilates Assessment
  • ✅Home Health / In-Home Evaluation
  • ✅PT Evaluation Form (Standard)
  • ✅PT Evaluation Form — Standard Layout
  • ✅Red Flags Screening (Risk Identification)
  • ✅Lower Extremity Limb Length Measurement

TOPIC 2 — VISIT DOCUMENTATION, PROGRESS NOTES & TRACKING

  • ✅Daily Progress Note (SOAP Format)
  • ✅Pilates Session Progress Note
  • ✅Patient Progress Note
  • ✅General Progress Note
  • ✅Attendance & Visit Log
  • ✅Intervention / Treatment Log
  • ✅Pain Rating (VAS / NRS)
  • ✅Therapeutic Exercise Checklist
  • ✅Scheduled Re-Evaluations
  • ✅Vital Signs Tracking
  • ✅Fall Risk Screening
  • ✅Home Health Routine Checklist

TOPIC 3 — PLAN OF CARE, HOME PROGRAMS & CLINICAL PROTOCOLS

  • ✅Individualized Plan of Care (POC)
  • ✅Home Health Plan of Care
  • ✅Condition-Specific Protocol Template
  • ✅Sport-Specific Rehab Protocol Template
  • ✅Injury Prevention Protocol
  • ✅Home Exercise Program (HEP) Prescription
  • ✅Senior Fitness Exercise Handout
  • ✅Senior Fitness Exercise Handout II
  • ✅Knee Rehab Exercise Handout
  • ✅Low Back Exercise Handout
  • ✅Post-Stroke Rehab Handout
  • ✅Evaluation Guidance Handout
  • ✅Post-Stroke Rehab Handout II
  • ✅Ankle Sprain Rehab Handout
  • ✅Fall Prevention Guide

TOPIC 4 — ADMINISTRATIVE, ETHICAL & COMPLIANCE-AWARE FORMS

  • ✅Informed Consent for Physical Therapy
  • ✅Photo & Media Release Authorization
  • ✅Service Termination / Cancellation Agreement
  • ✅Telehealth Consent Authorization
  • ✅Private Pay Service Agreement
  • ✅Agreement Termination (Mutual Release)
  • ✅Professional Ethics & Standards Overview
  • ✅Home Health Documentation Guidelines (Owner/Clinician)
  • ✅Best Practices Manual (Clinic Operations)
  • ✅Internal Policies & Procedures Guide
  • ✅Clinic Media Kit Template

TOPIC 5 — CLINICAL REPORTS, SUMMARIES & PROVIDER COMMUNICATION

  • ✅Physical Therapy Clinical Report
  • ✅Technical / Clinical Summary Report
  • ✅Discharge Summary Report
  • ✅PT Discharge Documentation
  • ✅Physical Therapy Clinical Opinion / Recommendation
  • ✅Physical Therapy Findings Report
  • ✅PT Referral / Provider Communication Form
  • ✅Provider Request for Diagnostic Testing (Template)
  • ✅Work/School Excuse Note
  • ✅Appointment Verification Note
  • ✅Return-to-Work Recommendation (Template)
  • ✅Physical Therapy Letter (General)

TOPIC 6 — OUTCOME MEASURES, QUESTIONNAIRES & FUNCTIONAL TOOLS

  • ✅Pain Scale (VAS)
  • ✅Oswestry Disability Index
  • ✅WOMAC
  • ✅Timed Up and Go (TUG)
  • ✅Berg Balance Scale
  • ✅Barthel Index
  • ✅Goniometry Tracking Sheet
  • ✅Manual Muscle Testing (Kendall)
  • ✅Borg Rating of Perceived Exertion (RPE)
  • ✅MRC Muscle Strength Scale
  • ✅MRC Dyspnea Scale
  • ✅Modified Oxford Scale
  • ✅Lawton IADL Scale
  • ✅Mini-Mental State Examination (MMSE)
  • ✅Katz Index of Independence in ADL
  • ✅Glasgow Coma Scale (GCS)
  • ✅Perme ICU Mobility Score
  • ✅RASS & Ramsay Sedation Scales
  • ✅Modified Ashworth Scale
  • ✅St. George’s Respiratory Questionnaire (SGRQ)
  • ✅Alberta Infant Motor Scale (AIMS)

TOPIC 7 — DISCHARGE & EPISODE-OF-CARE CLOSURE

  • ✅Discharge Agreement / Acknowledgment
  • ✅Final Treatment Summary
  • ✅Discharge Due to Non-Compliance / No-Show (Template)
  • ✅Continuity of Care Recommendations
  • ✅PT Discharge Documentation

TOPIC 8 — SPORTS REHABILITATION

  • ✅Sports Functional Assessment
  • ✅Training / Rehab Log
  • ✅Return-to-Sport Testing Checklist
  • ✅Sports Rehab Protocol Templates

TOPIC 9 — HOME HEALTH & IN-HOME CARE

  • ✅Home Health / In-Home Evaluation
  • ✅Home Accessibility Checklist
  • ✅Adapted Plan of Care
  • ✅Team Routine / Visit Coordination Sheet
  • ✅Home Health Documentation Guidelines
  • ✅Condition-Specific Care Guidance (In-Home)

TOPIC 10 — PRACTICE MANAGEMENT, FINANCIAL TRACKING & CONTROLS

  • ✅Monthly Financial Tracker
  • ✅Daily Cash Flow Tracker
  • ✅Cost Tracking Worksheet
  • ✅Internal Fee Reference Sheet
  • ✅Patient Estimate / Treatment Quote (Template)
  • ✅Payment Receipt
  • ✅Out-of-Network Reimbursement Receipt (Template)
  • ✅Receipt Book (Printable)
  • ✅Income Receipts Log
  • ✅Expense Receipts Log
  • ✅Monthly Financial Summary

TOPIC 11 — PATIENT CHARTS, FORMS & SUPPORTING DOCUMENTS

  • ✅Physical Therapy Patient Chart (Record Template)
  • ✅Provider Note Pad / Clinical Note Template
  • ✅Clinic Owner / Facility Information Template
  • ✅Weekly Planner
  • ✅Patient Visit Planner
  • ✅Resume Templates (2 Formats)

TOPIC 12 — STANDARD OPERATING PROCEDURES (SOPs)

General SOP Library
  • ✅93 SOPs for Physical Therapy (Complete Library)
SOPs by Setting / Specialty
  • ✅17 SOPs — Acute Care / ICU
  • ✅16 SOPs — Cardiopulmonary / Respiratory PT
  • ✅12 SOPs — Orthopedic PT
  • ✅8 SOPs — PT Evaluation Workflow
  • ✅8 SOPs — Therapeutic Exercise & Movement
  • ✅5 SOPs — Pelvic Health
  • ✅13 SOPs — Neurologic PT
  • ✅14 SOPs — Cleaning, Safety & Specialty Operations

TOPIC 13 — REFERENCES, QUICK GUIDES & STUDY MATERIALS

  • ✅PT Procedures Reference Guide (Template)
  • ✅Anatomy eBook — Musculoskeletal System
  • ✅Functional Anatomy eBook

Enroll Today and Receive 3 Exclusive Bonuses

BONUSES 1

Clinical & Compliance Documentation Guides (USA Edition)

You receive a comprehensive set of compliance-aware notices, consent forms, and administrative templates designed to support professional documentation standards commonly used in U.S.-based physical therapy practices, including HIPAA-aware workflows.

This means:

✅ Greater confidence when handling patient information
✅ Clear, professional documentation aligned with industry best practices
✅ Reduced risk of documentation gaps and omissions
✅ Access to structured templates most Physical Therapists never take the time to build

👉 This bonus alone delivers exceptional value and significantly enhances the overall system

BONUSES 2

Physical Therapist Productivity Mini-Planner

This mini-planner is designed to help Physical Therapists organize, prioritize, and manage their professional routines with clarity and intention.

Includes tools to support:

✅ Weekly and monthly planning
✅ SMART goal setting for measurable professional growth
✅ Session scheduling, time tracking, and progress overview
✅ Clear organization to reduce mental overload and missed tasks
✅ Greater visibility into productivity, workload, and outcomes

👉 Think of it as a personal practice management system — built to support focus, consistency, and sustainable growth.

Organized clinicians scale faster.

BONUSES 3

Discharge Documentation & Home Care Guidance Pack

This is more than a form — it’s a complete patient discharge experience designed to extend care beyond the final visit.

Includes:

✅ Professionally structured discharge documentation
✅ Clear, patient-friendly home care and follow-up guidance
✅ Support for continuity of care after the treatment episode
✅ Increased patient confidence, satisfaction, and trust
✅ A strong, memorable close to the care experience

👉 Patients who receive a clear and professional discharge process are more likely to remember the experience, value the care, and recommend the provider.

Below, we present a sample of the technical, detailed, and professional content that makes up this complete material.

What Physical Therapists Are Saying About the Documentation System

“I used to spend an incredible amount of time building evaluations and reports from scratch. I was also never fully confident that my documentation was complete or consistent.

After implementing this documentation system, everything changed. The templates are already structured, clear, and easy to use — and I was able to reduce my documentation time by nearly 40%.

Now I spend more time focusing on patient care and far less time on paperwork.”

Michael Anderson, PT, DPT

Orthopedic Physical Therapist

“In home health care, it was always a challenge to maintain consistent documentation while still creating individualized plans of care for each patient.

The materials in this system made a huge difference. I now have clear protocols, structured templates, and practical guidance tailored to different patient profiles.

It immediately improved both my confidence and my level of professionalism.”

Emily Carter, PT, DPT

Home Health Physical Therapist

“In the ICU setting, I was missing well-structured SOPs and reliable functional outcome measures that could actually support day-to-day clinical work.

This documentation system solved that gap completely. The SOPs are thorough, clearly organized, and easy to implement, and the evaluation templates significantly improved the efficiency of my workflow.

It became so useful that other members of my team started using it as well. Absolutely worth the investment.”

Paul Taylor

Acute Care / ICU Physical Therapist

PRICING & ACCES

Complete Physical Therapy Documentation System – USA Edition

  • Full access to 400+ professionally structured documentation templates
  • Templates covering clinical care, compliance-aware forms, SOPs, and practice management
  • Fully editable files — adapt to your specialty, setting, or clinic
  • 3 exclusive bonuses designed to enhance productivity, documentation quality, and patient experience
  • Lifetime access to all materials included in this edition
  • Saves hours of documentation time every week
  • Reduces documentation gaps and inconsistencies
  • Helps maintain professional documentation standards
  • Supports scalable workflows for individual clinicians and clinics
  • One-time payment. Long-term professional value.

Complete Physical Therapy Documentation System

One-Time Investment:

$47

✔ No subscriptions ✔ Lifetime acces ✔ Immediate access after checkout

Get Immediate Access to the Documentation System

30-Day Satisfaction Guarantee — Or Your Money Back

You have 30 full days to access the complete documentation system, review every template, explore all materials, and test how it fits into your daily clinical workflow.

If for any reason — for any reason at all — you feel this system is not the right fit for your practice, didn’t deliver the value you expected, or you simply change your mind, just request a refund within this period.

You’ll receive a 100% refund, promptly and without hassle.

No questions asked.
No complicated process.
No stress.

The decision is entirely yours.
There is no risk involved.

You only keep the system if you genuinely feel it adds value to your professional practice as a Physical Therapist.

Get Immediate Access to the Documentation System

FAQ

This system is designed to support documentation best practices commonly used by Physical Therapists in the United States, including HIPAA-aware workflows and professional documentation standards.

All templates are provided as organizational and educational tools, allowing you to adapt them to your specific practice setting and local requirements.

You can customize them to match your:

  • Practice setting

  • Clinical specialty

  • Clinic policies

  • Documentation preferences

This flexibility allows the system to work across different environments, specialties, and workflows.

Yes. The system is designed to be state-agnostic.

Because documentation requirements may vary slightly by state or organization, the templates are intentionally flexible, allowing you to adapt them to state-specific regulations, payer requirements, or internal clinic policies.

No. This system does not provide legal or medical advice.

It offers documentation templates and organizational tools intended to support professional practice. If you have questions about legal compliance or clinical decision-making, you should consult a qualified professional in your jurisdiction.

Immediately after checkout, you’ll receive secure access to the system.

You can download the templates and start using them right away. No waiting, no approvals, and no additional setup required.

This is a one-time payment.

There are no subscriptions, no recurring fees, and no hidden charges. Once you purchase, you keep access to the materials included in this edition.

Yes. Your purchase is protected by our 30-Day Satisfaction Guarantee.

You have 30 full days to explore the system and decide if it’s the right fit for your practice. If not, simply request a refund within that period and you’ll receive 100% of your money back, without hassle.

Get Immediate Access to the Documentation System