Upcoming Webinars 

Disclaimer

The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Menu
Log in


Log in

California Physical Therapy Documentation

What are a therapist’s documentation responsibilities?

A physical therapist shall document and sign in the patient record the following:

    • Examination and re-examination
    • Evaluation and reevaluation
    • Diagnosis
    • Prognosis and intervention
    • Treatment plan and modification of the plan of care
    • Each treatment provided by the physical therapist or a physical therapy aide
    • Discharge Summary

With respect to any care provided to the patient, the patient record shall indicate:

    • The date and nature of the service provided and
    • The name and title of any individual who provided such service, including the individual's role in that service. As used in this section, the term “service” does not include “non-patient related tasks”.

What are a therapy assistant’s documentation responsibilities?

The physical therapist assistant shall document and sign in the patient record any treatment provided by that individual

When does a therapist need to reassess the patient?

The physical therapist shall perform periodic re-evaluation of the patient as necessary and make adjustments in the patient's treatment program. The re-evaluation shall be documented in the patient's record.

How long do I need to maintain patient records?

Patient records must be maintained for at least seven (7) years following the discharge of the patient.

Records for minors must be maintained at least one (1) year after the minor has reached eighteen (18) years of age, and in no case less than seven (7) years.

Citations

16 CCR § 1399

Cal Bus. and Prof. Code § 2620.7


Powered by Wild Apricot Membership Software