Upcoming Webinars 

Disclaimer

The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Menu
Log in


Log in

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.

Citation

21 NCAC 48C .0102


Powered by Wild Apricot Membership Software