N.J. Admin. Code § 13:39A-3.1

Current through Register Vol. 56, No. 24, December 18, 2024

Section 13:39A-3.1 - Patient records

(a) A licensed physical therapist shall prepare and maintain for each patient a contemporaneous, permanent patient record that accurately reflects the patient contact with the licensed physical therapist whether in an office, hospital or other treatment, evaluation or consultation setting.

(b) A licensed physical therapist shall not falsify a patient's record.

(c) The patient record shall include, in addition to personal identifying information, consents, and disclosures, at least the following information:

1. The full name, as it appears on the license, of the licensee who rendered care, identification of licensure designation (PT or PTA), and license number. This information shall be legible and shall appear at least once on each page of the patient record, except as set forth at N.J.A.C. 13:39A-3.2(e);

2. Dates of all examinations, evaluations, physical therapy diagnoses, prognoses including the established plans of care, and interventions;

3. The findings of the examination including test results;

4. The conclusion of the evaluation;

5. The determination of the physical therapy diagnosis and prognosis;

6. Documentation of health care practitioner referrals, if any;

7. A plan of care establishing measurable goals of the intervention with stated time frames, the type of intervention, and the frequency and expected duration of intervention;

8. A note contemporaneous with each session, with the license number and signature or initials of the licensee who rendered care, that accurately represents the services rendered during the treatment sessions including, but not limited to, the components of intervention, the patient's response to intervention, and current status. If the licensee chooses to sign by means of initials, his or her complete signature and license number shall appear at least once on every page;

9. Home exercise programs, if provided to the patient;

10. Progress notes in accordance with stated goals at a frequency consistent with physical therapy diagnosis, evaluative findings, prognosis and changes in the patient's conditions;

11. Changes in the plan of care which shall be documented contemporaneously;

12. Communication with other health professionals relative to the patient's care;

13. A discharge summary which includes the reason for discharge from and outcome of physical therapy intervention relative to established goals at the time of discharge; and

14. Pertinent legal document(s).

(d) When a licensed physical therapist provides training in techniques for the prevention of injury, impairment, movement-related functional limitation or dysfunction that is not specifically designed for an individual, the licensed physical therapist shall not be required to maintain records that comply with (c) above. A licensed physical therapist that provides such training shall maintain records that include:

1. The name and license number of the licensed physical therapist who provided the training;

2. The date the training was provided;

3. A summarization of the information that was provided; and

4. Copies of any handouts provided.

(e) Patient records shall be maintained for at least seven years from the date of the last entry, unless another agency or entity requires the records to be kept for a longer time.

N.J. Admin. Code § 13:39A-3.1

Amended by 47 N.J.R. 3048(a), effective 12/7/2015

Amended by 53 N.J.R. 1500(b), effective 9/7/2021