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

Texas Physical Therapy Documentation

What must be included in the patient record?

At a minimum, documentation of physical therapy services must include the following:

    • Any referral authorizing treatment;
    • The initial examination and evaluation;
    • The plan of care;
    • Documentation of each treatment session by the PT or PTA providing the services;
    • Reevaluations as required by this section;
    • Any conferences between the PT and PTA, as described in this section; and
    • The discharge summary.

What are the physical therapist’s documentation responsibilities?

The physical therapist is responsible for the:

    • Evaluation;
    • Plan of care;
    • Reevaluation; and
    • Discharge summary

Development and implementation of the plan of care

    • The PT must develop a written plan of care, based on his evaluation, for each patient.
    • Treatment may not be provided by a PTA or aide until the plan of care has been established.
    • The plan of care must be reviewed and updated as necessary following a reevaluation of the patient's condition.
    • The plan of care or treatment goals may only be changed or modified by a PT.
    • A PTA may modify treatment techniques as indicated in the plan of care.
    • A PT or PTA must interact with the patient regarding his/her condition, progress and/or achievement of goals during each treatment session.

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:

    • At a minimum of once every sixty (60) days after treatment is initiated, or at a higher frequency as established by the PT; and
    • In response to a change in the patient's medical status that affects physical therapy treatment, when a change in the physical therapy plan of care is needed, or prior to any planned discharge.

What must the reevaluation include?

A reevaluation must include:

    • Direct physical therapist-to-patient interaction; and
    • A review of the plan of care with appropriate continuation, revision, or termination of treatment.

Discharge Summary

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.

Reference

3 Tex. Admin. Code ยง322.1



Powered by Wild Apricot Membership Software