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North Carolina Physical Therapy Documentation

What are a therapist’s documentation responsibilities?

A physical therapist shall document every evaluation and intervention or treatment including the following elements:

    • Authentication (signature and designation) by the physical therapist who performed the service;
    • Date of the evaluation or treatment;
    • Length of time of total treatment session or evaluation;
    • Patient status report;
    • Changes in clinical status;
    • Identification of specific elements of each intervention or modality provided. Frequency, intensity, or other details may be included in the plan of care and if so, do not need to be repeated in the daily note;
    • Equipment provided to the patient; and
    • Interpretation and analysis of clinical signs, symptoms, and response to treatment based on subjective and objective findings, including any adverse reactions to an intervention.

When does a therapist need to reassess the patient?

If a physical therapist assistant or physical therapy aide is involved in the patient care plan, a physical therapist shall reassess a patient every sixty (60) days or thirteen (13) visits, whichever occurs first.

What does a therapist need to document at the time of reassessment? 

At the time of reassessment the physical therapist shall document:

    • The patient's response to therapy intervention;
    • The patient's progress toward achieving goals; and
    • Justifications for continued treatment.

Patient records

A physical therapist shall, upon request by the patient of record, provide the original or copies of the patient’s treatment record to the patient, or to the patient’s designee.  A fee may be charged for the cost of reproducing copies. The documents requested shall be provided within thirty (30) days of the request and shall not be contingent upon current, past, or future physical therapy treatment or payment of services.


21 NCAC 48C .0102

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