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Arizona Physical Therapy Patient Records

What must be included in the patient record?

A physical therapist shall ensure that a patient record meets the following minimum standards:

Each entry in the patient record is:

    • Legible,
    • Accurately dated, and
    • Signed with the name and legal designation of the individual making the entry.

The patient record contains sufficient information to:

    • Identify the patient on each page of the patient record,
    • Justify the therapeutic intervention,
    • Document results of the therapeutic intervention,
    • Indicate advice or cautionary warnings provided to the patient,
    • Enable another physical therapist to assume the patient’s care at any point in the course of therapeutic intervention, and
    • Describe the patient’s medical history.

What are the physical therapist’s documentation responsibilities?

For each patient on each date of service, a physical therapist must provide and document all of the therapeutic intervention that requires the expertise of a physical therapist and must determine the use of physical therapist assistants and other assistive personnel to ensure the delivery of care that is safe, effective and efficient.  

What is required for an initial evaluation?

A physical therapist shall perform the initial evaluation of a patient.

The physical therapist who performs an initial evaluation shall make an entry that meets the standards in the patient record and document:

    • The patient’s reason for seeking physical therapy services;
    • The patient’s relevant medical diagnoses or conditions;
    • The patient’s signs and symptoms;
    • Objective data from tests or measurements;
    • The physical therapist’s interpretation of the results of the examination;
    • Clinical rationale for therapeutic intervention;
    • A plan of care that includes the proposed therapeutic intervention, measurable goals, and frequency and duration of therapeutic intervention; and
    • The patient’s prognosis.

What is required on each treatment note?

For each date that a therapeutic intervention is provided to a patient, the individual who provides the therapeutic intervention shall make an entry that meets the standards in the patient record and document:

    • The patient’s subjective report of current status or response to therapeutic intervention;
    • The therapeutic intervention provided or appropriately supervised;
    • Objective data from tests or measures, if collected;
    • Instructions provided to the patient, if any; and
    • Any change in the plan of care.

When is a reevaluation/reassessment required?

Perform a reevaluation and provide each therapeutic intervention for the patient that is done on the day of the reevaluation every fourth (4th) treatment visit or every thirty (30) days, whichever occurs first.

A physical therapist shall perform a re-evaluation when a patient fails to progress as expected, progresses sufficiently to warrant a change in the plan of care.

A physical therapist who performs a re-evaluation shall make an entry that meets the standards in the patient record and document:

    • The patient’s subjective report of current status or response to therapeutic intervention;
    • Assessment of the patient’s progress;
    • The patient’s current functional status;
    • Objective data from tests or measures, if collected;
    • Rationale for continuing therapeutic intervention; and
    • Any change in the plan of care.

What is required in the discharge summary?

A physical therapist shall document the conclusion of care in a patient’s record regardless of the reason that care is concluded.

If care is provided in an acute-care hospital, the entry made on the last date that a therapeutic intervention is provided constitutes documentation of the conclusion of care if the entry is made by a physical therapist.

If care is not provided in an acute-care hospital or if a physical therapist does not make the entry on the last date that a therapeutic intervention is provided, a physical therapist shall make an entry that meets the standards in the patient record and document:

    • The date on which therapeutic intervention terminated;
    • The reason that therapeutic intervention terminated;
    • Inclusive dates for the episode of care being terminated;
    • The total number of days on which therapeutic intervention was provided during the episode of care; 
    • The patient’s current functional status;
    • The patient’s progress toward achieving the goals in the plan of care required; and
    • The recommended discharge plan.

Unprofessional conduct related to documentation

Failing to maintain patient confidentiality without prior written consent of the patient or unless otherwise required by law.

Failing to maintain adequate patient records. For the purposes of this paragraph, “adequate patient records” means legible records that comply with board rules and that contain at a minimum an evaluation of objective findings, a diagnosis, the plan of care, the treatment record, a discharge summary and sufficient information to identify the patient.

Citations

A.R.S. ยง 32-2043

A.A.C. R4-24-303

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