Current through Register Vol. 50, No. 9, September 20, 2024
A. A written record of physical therapy
treatment shall be maintained for each patient. A complete record shall include
written documentation of prescription or referral (if such exists), initial
evaluation, treatment(s) provided, PT/PTA conferences, progress notes,
reevaluations or reassessments, and patient status at discharge all as defined
in §123
1. A prescription or referral, if it
exists, may initially be a verbal order and may be later confirmed in writing.
The verbal order shall be documented by the PT in the patient's
record.
2. An initial physical
therapy evaluation, as defined in
R.S.
37:2407(A)(1), shall be
created and signed by the PT performing the evaluation within seven days after
performing the evaluation.
3.
Progress note is the written documentation of the patients subjective status,
changes in objective findings, and progression to or regression from
established goals. A progress note shall be created and signed only by the
supervising PT of record or PTA. A progress note shall be written a minimum of
once per week, or if the patient is seen less frequently, then at every
visit.
4. Reassessment or
reevaluation is the written documentation which includes all elements of a
progress note, as well as the interpretation of objective findings compared to
the previous evaluation with a revision of goals and plan of care as indicated.
A reassessment shall be written at least once per month, or, if the patient is
seen less frequently, then at every visit. A reassessment shall be created and
signed by the supervising PT of record.
5. Treatment Record is the written
documentation of each patient visit which includes specific treatment and/or
any equipment provided which shall be signed or initialed by the Supervising PT
of Record or PTA. A treatment record shall be maintained only if a progress
note is not written for each patient visit. A treatment record may be in the
form of a checklist, flow sheet, or narrative.
6. Patient care conference is the
documentation of the meeting held between a PTA who is providing patient care
and the PT supervising that care to discuss the status of patients. This
conference shall be conducted where the PT and PTA are both physically present
at the same time and place, or through live telecommunication conducted in
accordance with all standards required by federal and state laws governing
privacy and security of a patient's protected health information. The patient
care conference shall be signed and dated by the PT and PTA and shall be
entered in the patient treatment record within five days of the conference,
documenting treatment recommendations and decisions made.
7. Discharge summary is the written
documentation of the reasons for discontinuation of care, degree of goal
achievement and a discharge plan which shall be created and signed by the
supervising PT of record. A discharge summary shall be written at the
termination of physical therapy care when feasible.
B. A licensee shall maintain accurate patient
treatment and billing records and shall not falsify, alter, or destroy such
records, the result of which would be to impede or evade investigation by the
board or other lawful authorities.
C. The documentation standards set forth
above do not mandate a particular format; however, a complete physical therapy
record must include these elements.
D. Forms of electronic signatures,
established pursuant to written policies and mechanisms to assure that only the
author can authenticate his own entry, are acceptable.
E. Documentation by a student must be
co-signed by the Supervising PT of Record or supervising PTA.
F. A written record of an initial screening
for wellness or preventive services shall be kept along with plans for
implementation of a wellness or preventive program.
AUTHORITY
NOTE: Promulgated in accordance with
R.S.
37:2405(A)(1) and Act 535 of
2009.
