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New York PT Documentation
Maintain written records for every visit or encounter with clients. Entries should be written in ink and signed by the licensee using full name and professional designation (e.g., PT or PTA) and date of service as well as:
Education Law is silent regarding the matter of PTs co-signing the notes of PTAs. However, because PTs are responsible for the evaluation, testing, interpretation, planning, and modification of patient programs, it is not uncommon for them to co-sign PTA notes as an indication that they are aware of the actions of PTAs in relation to their plan. Indeed, in some instances, hospitals and long term care facilities have developed policies that require PTs to co-sign the notes of PTAs under their supervision. (It is within the authority of a health care agency to develop and enforce policies and procedures that exceed state or federal requirements.)
Education law does not require that a licensed physical therapist co-sign the notes of a student, limited permittee or other licensee. The required supervision of a student, limited permittee or physical therapist assistant may be verified through clear documentation of the physical therapist’s review of patient progress and changes in the treatment plan. However, insurance companies and other third-party payers may require a co-signature for reimbursement.
Maintain all paper and electronic client records in a secure area accessible only to authorized persons and in a manner that lends itself to substantiating the records to be trustworthy and unalterable.
Be aware of retention requirements for client records, including the period required by law and requirements and allowed fees for providing patient access to records. All patient records must be retained for at least six (6) years. Obstetrical records and records of minor patients must be retained for at least six (6) years, and until one year after the minor patient reaches the age of 21 years. However, insurers, Medicaid, Medicare, or employers may have more stringent requirements that you should know.
In the event a record must be corrected or changed, line through, initial and date the change, and note the reason in a separate entry. Do not obliterate or destroy the original entry.
Patient Requests for Copies
It is unprofessional conduct for a licensee to fail to make available to a patient or client, upon request, copies of documents in the possession or under the control of the licensee which have been prepared and paid for by the patient/client. "Standards of Practice" may not limit access to records since such access is guaranteed by the previously cited provision. Records must be available for inspection within 10 days for a health care provider or 24 hours for a nursing home.
NY PT Board Practice Guideline 3