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Oregon PT Documentation
Record Keeping Responsibilities
The licensee who performs the physical therapy service shall prepare a complete and accurate record for every patient, regardless of whether compensation is given or received for the therapy services and regardless of whether the patient receives treatment pursuant to a referral or is self-referred.
A record shall be prepared on the date a physical therapy service is provided.
The permanent record shall contain information for every physical therapy service provided, the date the service was provided and the date the entry was made in the record. The permanent record of a physical therapy service shall be prepared within seven calendar days of the date the service was provided.
Either the permanent record or a record prepared on the date of service shall be readily accessible to a licensee prior to when that licensee provides subsequent treatment to the patient. "Readily accessible" means the authenticating licensee is able to produce the record immediately upon request.
The licensee who performs the physical therapy service shall authenticate the permanent record of the service that was performed. Authentication may be made by written signature or by computer. If authentication is by computer, the licensee shall not permit another person to use the licensee's password to authenticate the entry. Authentication may not be accomplished by the use of initials, except when a record entry identifying an error is authenticated. A rubber stamp may not be used to authenticate any entry in a patient record.
Non-licensees, including physical therapist aides, may prepare physical therapy treatment-related entries for the permanent patient record for authentication by the treating licensee. The requirement for authentication shall not apply to records not related to physical therapy treatment.
All entries shall be legible and permanent handwritten records shall be in ink.
Abbreviations may be used if they are recognized standard physical therapy abbreviations or are approved for use in the specific practice setting.
Errors and Additions
When an error in the permanent record is discovered, the error shall be identified and corrected. The erroneous entry shall be crossed out, dated and initialed or otherwise identified as an error in an equivalent written manner by the author of the erroneous entry.
Late entries or additions to entries in the permanent record shall be documented when the omission is discovered with the following written at the beginning of the entry: "late entry for (date)" or "addendum for (date)" and authenticated;
For purposes of the Board's enforcement of these rules, patient records shall be kept for a minimum of seven (7) years measured from the date of the most recent entry.