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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:
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:
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