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

(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:

(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:

(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:

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