What is required when a new patient is treated?

• A. A thorough intake, consent, and documentation of initial evaluation and proposed treatment.
• B. A brief welcome note and sign-off on insurance.
• C. Only a medical history without consent.
• D. A full physical therapy assessment.

Answer: (A)

The main idea is that before treating a new patient, you must establish a formal start to care: gather comprehensive information through intake, obtain informed consent, and document the initial evaluation along with the proposed treatment plan. This combination ensures the patient understands what will be done and agrees to it, while creating a clear clinical and billing record that justifies the care and sets a baseline for tracking progress. Without consent and proper documentation of the initial evaluation and plan, care isn’t properly authorized or defensible. A brief welcome note and insurance sign-off doesn’t address consent or the clinical basis for treatment. A medical history alone omits both consent and the evaluation/plan. While a full physical therapy assessment is important, the initial step must include the documented intake, consent, and the initial evaluation with the proposed treatment.