A PT documentation cheat sheet is a one-page guide to what every physical therapy note must contain so it shows skilled care, supports the CPT codes billed and meets Medicare rules. The short version: write the evaluation and plan of care with measurable goals, get the plan certified within 30 days, write a progress report at least every 10 treatment days, recertify at least every 90 days, and record total timed minutes and total treatment minutes on every daily note (CMS, September 2025).

Below you will find skilled physical therapy documentation examples, copy-ready templates for each note type, a skilled vs unskilled phrase list, a modalities cheat sheet, an acute care cheat sheet, a flow sheet template, and an interactive checklist that works out your Medicare deadlines.

PT documentation cheat sheet at a glance

Source: CMS MLN905365, Complying with outpatient rehabilitation therapy documentation requirements. For more detail, see our Medicare documentation requirements guide and Medicare progress note requirements.

PT documentation checklist and deadline calculator

Skilled physical therapy documentation examples

Medicare pays only for services that need the skills of a therapist. Notes that list exercises without showing your judgment are a frequent reason auditors call care "not skilled". Each example below swaps a vague phrase for one that shows what you did, why, and how the patient responded.

Words that show skilled care

• Action verbs: instructed, cued, progressed, modified, facilitated, assessed, adjusted, educated, graded, inhibited.
• Numbers: degrees, grades, sets and reps, distance, time, assist level, pain scale, outcome scores.
• Reasoning: "to address", "due to", "in order to", "which limits", linking the impairment to a functional goal.
• Response: what changed during or after the intervention, and what you will do next because of it.

More on phrasing: how to make your SOAP notes audit-proof and common SOAP note mistakes.

Physical therapy documentation templates and examples

The templates below follow the SOAP structure (Subjective, Objective, Assessment, Plan). Each is followed by a short example for the same fictional patient: a 52-year-old with right shoulder impingement. See how to write a SOAP note for physical therapists for a section-by-section guide.

1. Initial evaluation template

• S: chief complaint, onset and mechanism, pain (0 to 10, best and worst), aggravating and easing factors, prior level of function, patient goals, relevant history and medications.
• O: observation, ROM in degrees, MMT grades, special tests, palpation, neuro screen, functional tests, standardized outcome measure.
• A: PT diagnosis, problem list, prognosis, evaluation complexity and the reason skilled therapy is needed.
• P: interventions, frequency and duration, short- and long-term goals, home program, plan of care certification.

Example: S: Right shoulder pain for 6 weeks after painting a ceiling; 6/10 with overhead reaching, 2/10 at rest. Unable to place dishes on upper shelf. O: Flexion 140 degrees, abduction 120 degrees with painful arc 70 to 110 degrees; ER strength 4-/5; Hawkins-Kennedy and Neer positive. QuickDASH 45.5. A: Findings consistent with subacromial pain from rotator cuff weakness and posterior capsule tightness; good prognosis. Moderate complexity (97162). P: 2x/week for 6 weeks: therapeutic exercise, manual therapy, HEP. LTG: flexion 170 degrees and QuickDASH below 20 in 6 weeks so patient can reach upper shelves pain-free.

2. Daily treatment note template

• S: patient report since last visit, HEP adherence, pain today.
• O: each intervention with parameters, cues and assist level; re-measures taken today.
• A: response to treatment and progress toward goals.
• P: plan for next visit; total timed-code minutes, total treatment minutes and units billed.

Example: S: Pain 4/10 reaching overhead, did HEP 5 of 7 days. O: Therapeutic exercise 25 min (sidelying ER 3 x 10 at 2 lb, scaption to 90 degrees 3 x 10 with tactile cues for scapular depression); manual therapy 13 min (posterior glides, grade III). Flexion 150 degrees after treatment. A: Improved scapular control with fewer cues; flexion up 10 degrees since evaluation. P: Progress to 3 lb. Timed minutes 38, total treatment time 38 min, 2 units 97110, 1 unit 97140. See the 8-minute rule for unit math.

3. Progress report template

• Reporting period and visits completed.
• Same objective tests as the evaluation, with current values beside the baseline.
• Outcome measure rescore and change versus the MCID.
• Status of each goal (met, progressing, not met) and why.
• Justification for continued skilled care, or a discharge plan.

Example: Visits 1 to 10. Flexion 140 to 160 degrees; ER 4-/5 to 4/5; QuickDASH 45.5 to 27.3 (change 18.2, above MCID). STG 1 met; LTG 1 progressing. Continued skilled care needed to progress loading for overhead work; continue 2x/week for 3 weeks. More: SOAP notes vs progress notes.

4. Re-evaluation template

Use a re-evaluation (97164) only when there are new clinical findings, a significant change in condition, or the patient is not responding to the plan. Repeat the history review and standardized tests, update the assessment and prognosis, and revise the goals and plan of care. A routine progress report is not a re-evaluation.

5. Discharge summary template

• Reason for discharge (goals met, plateau, patient choice, referral).
• Final objective measures and outcome scores versus the evaluation.
• Goals met, and reasons for any not met.
• Home exercise program, education and follow-up recommendations.

Example: Discharged after 14 visits, goals met. Flexion 172 degrees, ER 5/5, QuickDASH 13.6. Independent with HEP; return if symptoms recur.

Evaluation complexity cheat sheet (97161, 97162, 97163)

All components must support the level you bill. Source: Noridian, therapy evaluative procedure codes. Our PT evaluation guide and PT CPT codes reference sheet go deeper.

Physical therapy modalities cheat sheet

Acute care physical therapy cheat sheet

In the hospital, the note has to show safety and discharge readiness as much as function. Document these on every acute care visit:

• Chart review: diagnosis, precautions (for example weight-bearing status, spinal or sternal precautions), lines, drains and oxygen.
• Vital signs before, during and after activity, including SpO2 and oxygen delivery, and any symptoms.
• Bed mobility, transfers and gait with distance, device and assist level.
• Patient and family education, and how the patient was left (bed alarm on, call light in reach).
• Discharge recommendation: home with or without services, inpatient rehab or skilled nursing, plus equipment needs.

Home health documentation follows the same principles. See SPRY for home health and mobile therapy.

Physical therapy flow sheet template

A flow sheet tracks the same exercises across visits so progression is easy to see and to justify. Copy this layout into your EMR or a spreadsheet:

Common PT documentation abbreviations

Full list: physical therapy abbreviations and PT vs PTA abbreviations.

Medicare PT documentation rules (2025 to 2026)

• Plan of care: must list diagnoses, long-term goals, type, amount, frequency and duration of therapy, signed and dated by the therapist who wrote it.
• Initial certification: the physician or NPP signs and dates the plan within 30 calendar days of the first treatment; verbal orders must be signed within 14 days.
• New since January 1, 2025: a signed and dated order or referral can substitute for the physician's signature on the initial plan if the plan was sent within 30 days but not returned. This does not apply to recertifications.
• Recertification: at least every 90 calendar days, or when the plan changes significantly.
• Progress report: at least once every 10 treatment days.
• Treatment notes: total timed-code minutes and total treatment minutes (timed and untimed) on every date of service.
• Above the KX threshold ($2,480 in 2026), notes must support medical necessity for the KX modifier. See the KX modifier guide.

CMS lists missing certifications, signatures, total time and progress reports among the most common documentation errors. Source: CMS MLN905365 and the Medicare Benefit Policy Manual, chapter 15.

How to use a PT documentation cheat sheet

1. Before the visit: review the last note, the plan of care dates and the visit count so you know if a progress report or recertification is due.
2. During the visit: capture parameters and the patient's response as you go, not from memory at the end of the day.
3. Use outcome measures: score a standardized measure at evaluation, progress reports and discharge. See our PROMs library.
4. Link every intervention to a goal: name the impairment and the function it limits.
5. Check before you sign: run the checklist above, confirm minutes match units, then sign with credentials and date.

Streamline PT documentation with SPRY

SPRY's SOAP and documentation tools build these elements into each note template, carry forward measures from the evaluation, and flag when a progress report or recertification is due. SPRY Ally and the AI scribe for physical therapy turn the session into a draft SOAP note for you to review. Book a free demo.

Frequently asked questions

What should a PT documentation cheat sheet include?

The required elements for each note type: evaluation and plan of care, daily notes, progress reports, re-evaluations and discharge summaries, plus Medicare deadlines, evaluation complexity rules and common abbreviations.

What are examples of skilled physical therapy documentation?

Notes that show your clinical judgment, such as "tactile cues for right heel strike reduced foot drag from 6 of 10 to 2 of 10 steps", rather than "gait training x 15 min". Include parameters, cues, the patient's response and the link to a functional goal.

How often does Medicare require a PT progress report?

At least once every 10 treatment days. The report must show objective progress toward goals and why skilled care is still needed.

How often does a PT plan of care need recertification?

Medicare requires recertification at least every 90 calendar days after treatment starts, or sooner if the plan of care changes significantly.

What is PT charting?

PT charting is recording each patient encounter in the medical record: the evaluation, daily treatment notes, progress reports and discharge summary. The chart is a legal record and supports billing.

How do you document CPT 97110?

Name the body region and impairment, list each exercise with sets, reps and load, describe your skilled cues or progression, record the patient's response, and note the timed minutes that support the units billed.

How do you document manual therapy?

Record the technique, grade, joint or tissue treated, duration, and the measurable response, for example internal rotation improving from 35 to 45 degrees after posterior glides.

Do I need to record total treatment time on every note?

Yes for Medicare. Each date of service needs the total timed-code minutes and the total treatment minutes, including untimed codes.

Can a PTA write a progress report?

Medicare expects the PT to write and sign the clinical judgments in the progress report. A PTA can document treatment notes and objective data under the plan of care.

Sources

• CMS MLN905365: Complying with outpatient rehabilitation therapy documentation requirements (September 2025)
• CMS Medicare Benefit Policy Manual, chapter 15
• Noridian: therapy evaluative procedure codes
• APTA: Physical therapy documentation of patient and client management