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Texas PT 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 PT’s documentation responsibilities?

Physical therapy plan of care development and implementation.

    • 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. (5) 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 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.

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.


22 Tex. Admin. Code ยง322.1

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