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New Jersey Physical Therapy Documentation

What are a therapist’s documentation responsibilities?

A licensed physical therapist shall prepare and maintain for each patient a contemporaneous, permanent patient record that accurately reflects the patient contact with the licensed physical therapist whether in an office, hospital or other treatment, evaluation or consultation setting.

What must be included in the patient record?

The patient record shall include, in addition to personal identifying information, consents and disclosures, at least the following information:

    • The full name, as it appears on the license, of the licensee who rendered care, identification of licensure designation (PT or PTA), and license number. This information shall be legible and shall appear at least once on each page of the patient record, except as set forth at N.J.A.C. 13:39A-3.2(e);
    • Dates of all examinations, evaluations, physical therapy diagnoses, prognoses including the established plans of care, and interventions;
    • The findings of the examination including test results;
    • The conclusion of the evaluation;
    • The determination of the physical therapy diagnosis and prognosis;
    • Documentation of health care practitioner referrals, if any;
    • A plan of care establishing measurable goals of the intervention with stated time frames, the type of intervention, and the frequency and expected duration of intervention;
    • A note contemporaneous with each session, with the license number and signature or initials of the licensee who rendered care, that accurately represents the services rendered during the treatment sessions including, but not limited to, the components of intervention, the patient's response to intervention and current status. If the licensee chooses to sign by means of initials, his or her complete signature and license number shall appear at least once on every page;
    • Progress notes in accordance with stated goals at a frequency consistent with physical therapy diagnosis, evaluative findings, prognosis and changes in the patient's conditions;
    • Changes in the plan of care which shall be documented contemporaneously;
    • Communication with other health professionals relative to the patient's care;
    • A discharge summary which includes the reason for discharge from and outcome of physical therapy intervention relative to established goals at the time of discharge; and
    • Pertinent legal document(s).

Patient records shall be maintained for at least seven (7) years from the date of the last entry, unless another agency or entity requires the records to be kept for a longer time.

Release of Patient Records

The PT shall provide one (1) copy of the patient's record of physical therapy treatment within fifteen (15) days of a written request by the patient or any person whom the patient has designated to receive that record.

Copy Fee

The PT may require a record request to be in writing and may charge a fee for the reproduction of records, which shall be no greater than $1.00 per page or $100.00 for the entire record, whichever is less. (If the record requested is less than 10 pages, the licensee may charge up to $10.00 to cover postage and the miscellaneous costs associated with retrieval of the record.) If the patient requests a summary in lieu of the actual record, the charge for the summary shall not exceed the cost that would be charged for the actual record.

Illegible Documents

If the patient or a subsequent treating health care professional is unable to read the treatment record, either because it is illegible or prepared in a language other than English, the licensed physical therapist shall provide a transcription at no cost to the patient or the person requesting the record.

Release to a third-party

Where the patient has requested the release of a professional treatment record or a portion thereof to a specified individual or entity, in order to protect the confidentiality of the records, the licensed physical therapist shall:

    • Secure and maintain a current written authorization, bearing the signature of the patient or an authorized representative;
    • Assure that the scope of the release is consistent with the request; and
    • Forward the records to the attention of the specific individual or entity identified and mark the material "Confidential."

Citations

N.J.A.C. ยง 13:39A-3.1


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