Current through Register Vol. 56, No. 18, September 16, 2024
(a) A licensed physical therapist shall prepare
and maintain for each patient a contemporaneous, permanent patient record that accurately reflects the
patient contact with the licensed physical therapist whether in an office, hospital or other treatment,
evaluation or consultation setting.
(b) A licensed physical
therapist shall not falsify a patient's record.
(c) The patient
record shall include, in addition to personal identifying information, consents, and disclosures, at least
the following information:
1. The full name, as it appears on the license,
of the licensee who rendered care, identification of licensure designation (PT or PTA), and license number.
This information shall be legible and shall appear at least once on each page of the patient record, except
as set forth at 13:39A-3.2(e);
2. Dates of all examinations, evaluations, physical therapy diagnoses,
prognoses including the established plans of care, and interventions;
3. The findings of the examination including test results;
4. The conclusion of the evaluation;
5. The determination of the physical therapy diagnosis and
prognosis;
6. Documentation of health care practitioner
referrals, if any;
7. A plan of care establishing measurable
goals of the intervention with stated time frames, the type of intervention, and the frequency and expected
duration of intervention;
8. A note contemporaneous with each
session, with the license number and signature or initials of the licensee who rendered care, that accurately
represents the services rendered during the treatment sessions including, but not limited to, the components
of intervention, the patient's response to intervention, and current status. If the licensee chooses to sign
by means of initials, his or her complete signature and license number shall appear at least once on every
page;
9. Home exercise programs, if provided to the
patient;
10. Progress notes in accordance with stated goals at a
frequency consistent with physical therapy diagnosis, evaluative findings, prognosis and changes in the
patient's conditions;
11. Changes in the plan of care which shall
be documented contemporaneously;
12. Communication with other
health professionals relative to the patient's care;
13. A
discharge summary which includes the reason for discharge from and outcome of physical therapy intervention
relative to established goals at the time of discharge; and
14.
Pertinent legal document(s).
(d) When a licensed
physical therapist provides training in techniques for the prevention of injury, impairment, movement-related
functional limitation or dysfunction that is not specifically designed for an individual, the licensed
physical therapist shall not be required to maintain records that comply with (c) above. A licensed physical
therapist that provides such training shall maintain records that include:
1. The name and license number of the licensed physical therapist who
provided the training;
2. The date the training was
provided;
3. A summarization of the information that was
provided; and
4. Copies of any handouts provided.
(e) Patient records shall be maintained for at least seven years
from the date of the last entry, unless another agency or entity requires the records to be kept for a longer
time.
