Documentation and the Need for a Separate Procedure Note in Virginia

    • July 9, 2018 at 2:06 pm #17104
      karaprato
      Member

      The Board of Physical Therapy Guidance on Dry Needling in the Practice of Physical Therapy states that…
      “If dry needling is performed, a separate procedure note for each treatment is required, and notes must indicate how the patient tolerated the technique as well as the outcome after the procedure.”

      Our clinic documents in WebPT and we have been doing a separate case note for IDN procedures in addition to documenting in the daily note for that date of service. Does anyone else in Virginia do anything different?? Do we really need to do a separate case note in addition to our daily note or is the documentation in the daily note sufficient enough??

      Just trying to figure out what is needed to meet the requirements for a “separate procedure note” and making sure we are not being redundant with our documentation. Any information/advice would be appreciated!! Thanks.

    • August 16, 2019 at 10:11 am #29435
      smidkiff
      Member

      I would love to know some input on this question also.

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