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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:

    • Acute care: at least every seven (7) to ten (10) days.
    • Outpatient, rehabilitation, home health, skilled nursing facility: at least every thirty (30) days.
    • Long term chronic care facility and educational school setting: at least every ninety (90) days.

Patient Encounters

Each visit or patient encounter must be documented, including at a minimum:

    • Current patient status and self-reporting;
    • Change of status as related to the plan of care, if applicable;
    • Communication or consultations regarding patient plan of care, if applicable;
    • Adverse reactions to interventions, if applicable;
    • Identification of specific interventions provided (type, amount, frequency, intensity, and duration) as appropriate;
    • Factors that modify intensity or frequency of interventions;
    • Progress on goals with the plan of care, if applicable;
    • Equipment provided, if applicable; and
    • Other pertinent information.

Citations

259 CMR 5.03



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