La. Admin. Code tit. 46 § LIV-341

Current through Register Vol. 50, No. 11, November 20, 2024

Section LIV-341 - Documentation Standards [Formerly Section 323]

A. A written record of physical therapy treatment shall be maintained for each patient. A complete record shall include written documentation of prescription or referral (if such exists), initial evaluation, treatment(s) provided, PT/PTA conferences, progress notes, reevaluations or reassessments, and patient status at discharge all as defined in §123

1. A prescription or referral, if it exists, may initially be a verbal order and may be later confirmed in writing. The verbal order shall be documented by the PT in the patient's record.

2. An initial physical therapy evaluation, as defined in R.S. 37:2407(A)(1), shall be created and signed by the PT performing the evaluation within seven days after performing the evaluation.

3. Progress note is the written documentation of the patients subjective status, changes in objective findings, and progression to or regression from established goals. A progress note shall be created and signed only by the supervising PT of record or PTA. A progress note shall be written a minimum of once per week, or if the patient is seen less frequently, then at every visit.

4. Reassessment or reevaluation is the written documentation which includes all elements of a progress note, as well as the interpretation of objective findings compared to the previous evaluation with a revision of goals and plan of care as indicated. A reassessment shall be written at least once per month, or, if the patient is seen less frequently, then at every visit. A reassessment shall be created and signed by the supervising PT of record.

5. Treatment Record is the written documentation of each patient visit which includes specific treatment and/or any equipment provided which shall be signed or initialed by the Supervising PT of Record or PTA. A treatment record shall be maintained only if a progress note is not written for each patient visit. A treatment record may be in the form of a checklist, flow sheet, or narrative.

6. Patient care conference is the documentation of the meeting held between a PTA who is providing patient care and the PT supervising that care to discuss the status of patients. This conference shall be conducted where the PT and PTA are both physically present at the same time and place, or through live telecommunication conducted in accordance with all standards required by federal and state laws governing privacy and security of a patient's protected health information. The patient care conference shall be signed and dated by the PT and PTA and shall be entered in the patient treatment record within five days of the conference, documenting treatment recommendations and decisions made.

7. Discharge summary is the written documentation of the reasons for discontinuation of care, degree of goal achievement and a discharge plan which shall be created and signed by the supervising PT of record. A discharge summary shall be written at the termination of physical therapy care when feasible.

B. A licensee shall maintain accurate patient treatment and billing records and shall not falsify, alter, or destroy such records, the result of which would be to impede or evade investigation by the board or other lawful authorities.

C. The documentation standards set forth above do not mandate a particular format; however, a complete physical therapy record must include these elements.

D. Forms of electronic signatures, established pursuant to written policies and mechanisms to assure that only the author can authenticate his own entry, are acceptable.

E. Documentation by a student must be co-signed by the Supervising PT of Record or supervising PTA.

F. A written record of an initial screening for wellness or preventive services shall be kept along with plans for implementation of a wellness or preventive program.

La. Admin. Code tit. 46, § LIV-341

Promulgated by the Department of Health and Human Resources, Board of Physical Therapy Examiners, LR 13:750 (December 1987), amended by the Department of Health and Hospitals, Board of Physical Therapy Examiners, LR 15:389 (May 1989), LR 21:395 (April 1995), LR 26:1447 (July 2000), LR 28:1981 (September 2002), LR 34:1911 (September 2008), amended by the Physical Therapy Board, LR 37:3053 (October 2011), Amended by the Department of Health, Physical Therapy Board, LR 442183 (12/1/2018), Amended by LR 471138 (8/1/2021).

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:2405(A)(1) and Act 535 of 2009.