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Texas Physical Therapy Documentation
What must be included in the patient record?
At a minimum, documentation of physical therapy services must include the following:
What are the physical therapist’s documentation responsibilities?
The physical therapist is responsible for the:
Development and implementation of the plan of care
When is a reevaluation/reassessment required?
Provision of physical therapy treatment by a PTA or an aide may not continue if the PT has not performed a reevaluation:
What must the reevaluation include?
A reevaluation must include:
The PT must provide final documentation for discharge of a patient, including patient response to treatment at the time of discharge and any necessary follow-up plan. A PTA may participate in the discharge summary by providing subjective and objective patient information to the supervising physical therapist.
3 Tex. Admin. Code §322.1