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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.

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Oregon PT Treatment Notes

The record of treatment for each patient visit shall include at a minimum:

    • Subjective status of patient;
    • Specific treatments, information, and education provided;
    • Objective data from tests and measurements conducted;
    • Assessment of the patient's response to treatment, including but not limited to:
      • Patient status, progression or regression;
      • Changes in objective and measurable findings as they relate to existing goals; and
      • Adverse reactions to treatment.
    • Changes in the plan of care.

Treatment by PTA

When treatment is provided by a physical therapist assistant, the physical therapist assistant shall record and authenticate those services. If the supervising physical therapist records and authenticates treatment provided by the physical therapist assistant, the physical therapist shall document which services were provided that day by the physical therapist assistant.

Treatment by Aide

When treatment is provided or assisted by an aide, the aide may only document in the patient record[s] objective information about the treatment provided by the aide. When a supervising physical therapist assistant or supervising physical therapist authenticates treatment provided by an aide, the therapist shall document which services were provided that day by the aide.

Citation

OAR 848-040-0150


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