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Arizona PT Patient Records
What must be included in the patient record?
A PT must ensure that a patient record meets the following minimum standards:
Each entry in the patient record is:
The patient record contains sufficient information to:
What are the PT's documentation responsibilities?
For each patient on each date of service, a PT must provide and document all of the therapeutic intervention that requires the expertise of a PT and must determine the use of PTAs and other assistive personnel to ensure the delivery of care that is safe, effective and efficient.
What is required for an initial evaluation?
A PT must perform the initial evaluation of a patient.
The PT who performs an initial evaluation shall make an entry that meets the standards in the patient record and document:
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:
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 PT 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 PT who performs a re-evaluation shall make an entry that meets the standards in the patient record and document:
What is required in the discharge summary?
A PT 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 PT.
If care is not provided in an acute-care hospital or if a PT does not make the entry on the last date that a therapeutic intervention is provided, a PT shall make an entry that meets the standards in the patient record and document:
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.
A.R.S. § 32-2043