Sec. 10.38.03.02-1. Requirements for Documentation

A. The physical therapist shall document legibly the patient's chart each time the patient is seen for:

(1) The initial visit, by including the following information:

(a) Date;

(b) Condition, or diagnosis, or both, for which physical therapy is being rendered;

(c) Onset;

(d) History, if not previously recorded;

(e) Evaluation and results of tests (measurable and objective data);

(f) Interpretation;

(g) Goals;

(h) Modalities, or procedures, or both, used during the initial visit and the parameters involved including the areas of the body treated;

(i) Plan of care including suggested modalities, or procedures, or both, number of visits per week, and number of weeks; and

(j) Signature, title (PT), and license number.

(2) Subsequent visits, by including the following information (progress notes):

(a) Date;

(b) Cancellations, no-shows;

(c) Modalities, or procedures, or both, with any changes in the parameters involved and areas of body treated;

(d) Objective status;

(e) Response to current treatment, if any;

(f) Changes in plan of care; and

(g) Signature, title (PT), and license number, although the flow chart may be initialed.

(3) Reevaluation, by including the following information in the report, which may be in combination with the visit note, if treated during the same visit:

(a) Date;

(b) Number of treatments since the initial evaluation or last reevaluation;

(c) Reevaluation, tests, and measurements of areas of body treated;

(d) Changes from previous objective findings;

(e) Interpretation of results;

(f) Goals met or not met and reasons;

(g) Updated goals;

(h) Updated plan of care including recommendations for follow-up; and

(i) Signature, title (PT), and license number;

(4) Discharge, by including the following information in the discharge summary, which may be combined with the final visit note, if seen by the physical therapist on the final visit and written by the physical therapist:

(a) Date;

(b) Reason for discharge;

(c) Objective status;

(d) Recommendations for follow-up; and

(e) Signature, title (PT), and license number.

B. Notwithstanding §A(4) of this regulation, a physical therapist may direct a physical therapist assistant to treat a patient on a final visit.

C. The physical therapist assistant shall document the patient's chart each time the patient is seen by the physical therapist assistant following the physical therapist's initial evaluation or reevaluation by including the following:

(1) Date;

(2) Cancellations and no-shows;

(3) Modalities, procedures, or both, including parameters involved, and areas of body treated;

(4) Objective status;

(5) Response to treatment, if any;

(6) Continuation of plan as established by the physical therapist or change of plan as authorized by the physical therapist; and

(7) Signature, title (PTA), and license number, although the flow chart may be initialed.

D. Subsequent visits, as referred to in §A(2) of this regulation, in the same day by the same physical therapist do not require separate progress notes unless there is a change in the patient's status.

E. Ongoing Communications. Both the physical therapist and the physical therapist assistant shall document ongoing communication between the physical therapist and physical therapist assistant regarding changes in a patient's status and treatment plan.