Section 640.Sec. 23 - NEWDocumentation of the care provided to each patient must be complete and must include, without limitation:
1. For an initial evaluation: (a) History, systems review and tests and measures.(b) Synthesis of data to include identification of the level of impairment, activity limitations and participation restrictions.(c) Physical therapy diagnosis and prognosis.(d) Predicted level of improvement.(e) Goals, treatment interventions, proposed frequency, duration and discharge plans.2. For daily notes: (b) Treatment interventions, responses to treatment interventions and factors that modify frequency or intensity of treatment interventions.(c) Progression within the plan of care and the plan for the next visit.3. For reevaluation or reassessment, data from repeated or new examination elements, sufficient to evaluate progress and to modify or redirect treatment interventions.4. For discharge: (a) Summary of progression towards goals.(b) Discharge instructions, as the availability of the patient allows.Nev. Admin. Code § 640.Sec. 23
Added to NAC by Bd. of Phys. Therapy Exam'rs by R124-21A, eff. 12/17/2022