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