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 Supervision and Documentation

Treatment and Supervision

PT

PTA

Aides

PT Student

PTA Student

Supervision Required

No

Works under PT

On-site by PT or PTA

By PT or PTA

By PT or PTA

Order Interpretation

Yes

No

No

Yes

No

Evaluation

Yes

No

No

Yes

No

Establish Treatment Program

Yes

No

No

Yes

No

Performs Treatment Program

Yes

Yes

Yes, if activity is commensurate with training & ability and under appropriate supervision

Yes

Yes, if activity is commensurate with training & ability and under appropriate supervision

Modifies Program

Yes

Minor changes

No

Yes

Minor changes

Final Visit

Yes

Yes, but PT decides when treatment ends

No

Yes

No

Charts

PT

PTA

Aides

PT Student

PTA Student

Daily Notes

Yes

Yes

Description of treatment or recording patient's comments

Yes

Yes

Discharge Evaluation Summary

Yes

No

No

Yes

No

Brief Discharge Notes

Yes

Yes

No

Yes

Yes

Notes Required to be Cosigned

Initial Evaluations

No

N/A

N/A

Yes

N/A

Reassessments

No

N/A

N/A

Yes

Yes

Notes with Significant Incidents

No

Yes

Yes - limited to description of incident only

Yes

Yes

Daily Notes

No

No

Yes

Yes

Yes

Discharge Evaluation Summary

N/A

N/A

N/A

Yes

N/A

Notes

A PTA may only supervise a PT student performing the procedures the PTA is licensed and competent to perform. (For example: a PTA may not supervise a PT student who is doing an evaluation.)

If the note is strictly a summary that reviews information in the chart and does not include evaluation or assessment.

A PTA may only cosign a PT student’s treatment note when the PTA is licensed and competent to perform the treatment procedures. (For example: a PTA may not cosign a PT student’s evaluation.)

Types of Supervision PTA by PT

- PT must be responsible for adequate supervision of PTA at all times.

- PT must be available to the PTA at all times and must be knowledgeable about the patient.

- PT must follow-up on patient and program as appropriate.

- PT must be involved in discharge planning.

Aide by PT or PTA - On-site supervision.

*Location of Supervision On-site - in same facility (or campus, if facility consists of more than 1 building). Can vary depending on experience of aide and nature of treatment.

Citation

Position Statement – North Carolina Board of Physical Therapy Examiners 1. Supervision and Documentation (Notes) Posted – 1998 Updated – April 5, 2010, September 23, 2010, June 13, 2013, Oct 21, 2014, June 17, 2015


Powered by Wild Apricot Membership Software