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Georgia PT Documentation

What are the physical therapist’s documentation responsibilities?

Perform an initial evaluation of the patient.

Develop a plan of care, including short and long-term goals.

Identify and document precautions, special programs, contraindications, goals, anticipated progress, and plans for re-evaluation.

It is the PT’s responsibility to re-evaluate the patient, modify the plan of care when necessary, perform the final evaluation, and establish a follow-up plan.

Unprofessional conduct related to documentation

Failing to provide an evaluation on each patient and establishing a physical therapy diagnosis.

Failing to formulate and record in the patient's record a treatment program based upon the evaluation and any other information available.

Failing to perform periodic evaluation of the patient and documenting the evaluations in the patient's record and to make adjustments to the patient's treatment program as progress warrants.

Failing to formulate and record a patient's discharge plan.

Reference

Ga. Comp. R. & Regs. R.  490-9-.04

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