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California PT 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.


16 CCR § 1399

Cal Bus. and Prof. Code § 2620.7

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