Oregon Administrative Rules
Chapter 848 - OREGON BOARD OF PHYSICAL THERAPY
Division 40 - MINIMUM STANDARDS FOR PHYSICAL THERAPY PRACTICE AND RECORDS
Section 848-040-0150 - Standards For The Documentation of Treatment Provided

Universal Citation: OR Admin Rules 848-040-0150

Current through Register Vol. 63, No. 9, September 1, 2024

(1) The permanent record of treatment for each patient visit shall include at a minimum:

(a) Subjective status of patient;

(b) Specific treatments and education provided;

(c) Objective data from tests and measurements conducted;

(d) Assessment of the patient's response to treatment, including but not limited to:
(A) Patient status, progression or regression;

(B) Changes in objective and measurable findings as they relate to existing goals;

(C) Adverse reactions to treatment; and

(e) Changes in the plan of care.

(2) When treatment is provided by a physical therapist assistant, the physical therapist assistant shall record and authenticate those services. If the supervising physical therapist records and authenticates treatment provided by the physical therapist assistant, the physical therapist shall document which services were provided that day by the physical therapist assistant. When treatment is provided or assisted by an aide, the aide may only document in the patient records objective information about the treatment provided by the aide. When a supervising physical therapist assistant or supervising physical therapist authenticates treatment provided by an aide, the therapist shall document which services were provided that day by the aide.

Statutory/Other Authority: ORS 688.160

Statutes/Other Implemented: ORS 688.160, 688.010 & 688.210

Disclaimer: These regulations may not be the most recent version. Oregon may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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