Code of Massachusetts Regulations
259 CMR - BOARD OF REGISTRATION OF ALLIED HEALTH PROFESSIONALS
Title 259 CMR 5.00 - Physical Therapists
Section 5.03 - Assessment and Documentation of Physical Therapy Treatment Program

Universal Citation: 259 MA Code of Regs 259.5

Current through Register 1531, September 27, 2024

(1) A physical therapist shall document, date, and authenticate the patient's clinical examination, evaluation, diagnosis, prognosis, progress, and any clinical assessment of the patient's condition which results in an alteration in the patient's Plan of Care.

(2) This documentation shall be contained in the patient's ongoing treatment notes or in a formal review of the Plan of Care (or reevaluation). If by formal review of the Plan of Care (or reevaluation), it must be completed in the particular work setting by a Physical Therapist of Record within the following timeframes:

(a) Acute care: at least every seven to ten days.

(b) Outpatient, rehabilitation, home health, skilled nursing facility: at least every 30 days.

(c) Long term chronic care facility and educational school setting: at least every 90 days.

(3) When care is rendered by a physical therapist assistant or Physical Therapy Assistant Student, the documentation shall be contained in the patient's ongoing treatment note.

(4) A physical therapist, Physical Therapy Student, physical therapist assistant and Physical Therapy Assistant Student providing physical therapy intervention(s) shall legibly document, date, and authenticate all care that is provided:

(a) Using their name as appearing on their professional license or legal name if a student;

(b) Professional designation as outlined in 259 CMR 5.04; and

(c) Their license number if applicable.

(5) The supervising physical therapist shall co-sign all documentation provided by physical therapy students.

(6) The supervising physical therapist or physical therapist assistant shall co-sign all documentation provided by Physical Therapy Assistant Students.

(7) Physical therapist assistants are not required to have their documentation co-signed; however, Physical Therapy Students and Physical Therapy Assistant Students must have their notes co-signed by their Clinical Instructor (CI).

(8) Persons practicing pursuant to M.G.L. c. 112, § 23C shall have their documentation co-signed by their directing licensee.

(9) Each visit or patient encounter must be documented, including at a minimum:

(a) Current patient status and self-reporting;

(b) Change of status as related to the Plan of Care, if applicable;

(c) Communication or consultations regarding patient Plan of Care, if applicable;

(d) Adverse reactions to interventions, if applicable;

(e) Identification of specific interventions provided (type, amount, frequency, intensity, and duration) as appropriate;

(f) Factors that modify intensity or frequency of interventions;

(g) Progress on goals with the Plan of Care, if applicable;

(h) Equipment provided, if applicable; and

(i) Other pertinent information.

(10) Billing, as a form of documentation, must accurately reflect the documented treatment interventions.

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