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Massachusetts Physical Therapy Documentation
What are a therapist’s documentation responsibilities?
A physical therapist shall document, date, and authenticate the patient’s clinical examination, evaluation, diagnosis, prognosis, progress, and any clinical assessment of the patient’s condition which results in an alteration in the patient’s plan of care.
When does a therapist need to reassess the patient?
This documentation shall be contained in the patient’s ongoing treatment notes or in a formal review of the plan of care (or reevaluation). If by formal review of the plan of care (or reevaluation), it must be completed in the particular work setting by a physical therapist of record within the following timeframes:
Each visit or patient encounter must be documented, including at a minimum:
259 CMR 5.03