848-040-0110 General Standards for Record Keeping (1) The licensee who performs the physical therapy service shall prepare a complete and accurate record for every patient, regardless of whether compensation is given or received for the therapy services and regardless of whether the patient receives treatment pursuant to a referral or is self-referred. (2) Sufficient written documentation shall be prepared on the same date a physical therapy service is provided. (3) If the written documentation of the service provided described in (2) is made outside of the patient’s record, such as but not limited to, when handwritten notes are not documented directly in the electronic record, or when the encounter is outside the clinic where the patient’s record is stored, that written documentation must be added to the patient’s record in a timely manner appropriate for the care setting, but never longer than seven calendar days from the date the service was provided. Such entries must include date of entry if different than date of service. (4) The licensee who performs the physical therapy service shall authenticate the documentation of the service that was performed. Authentication may be made by written signature or by electronic means. If authentication is by electronic means, the licensee shall not permit another person to use the licensee's password to authenticate the entry. Authentication may not be accomplished by the use of initials, except when an entry identifying an error is authenticated. A rubber stamp may not be used to authenticate any entry in a patient record. (5) Non-licensees, including physical therapist aides, may prepare physical therapy treatment-related entries for the patient record for authentication by the treating licensee. The requirement for authentication shall not apply to records not related to physical therapy treatment. (6) All documentation shall be readily accessible to a licensee prior to when that licensee provides subsequent treatment to the patient. "Readily accessible" means the authenticating licensee is able to produce the record immediately upon request. (7) All entries shall be legible and permanent handwritten records shall be in ink. (8) Abbreviations may be used if they are defined and accessible to all individuals accessing the patient's record. (9) When an error in the patient record is discovered, the error shall be identified and corrected. The erroneous entry shall be crossed out, dated and initialed or otherwise identified as an error in an equivalent written manner by the author of the erroneous entry. (10) Late entries or additions to entries in the patient record shall be documented when the omission is discovered with the following written at the beginning of the entry: "late entry for (date)" or "addendum for (date)" and authenticated; (11) Treatment provided by a student physical therapist (SPT) may be documented either by the SPT or by the supervising therapist. Documentation by a SPT shall be signed by the student and authenticated by a supervising physical therapist. (12) Treatment provided by a student physical therapist assistant (SPTA) may be documented either by the SPTA or by the supervising therapist or physical therapist assistant. Documentation by a SPTA shall be signed by the student and authenticated by a supervising physical therapist or supervising physical therapist assistant. (13) Documentation by a person who holds a physical therapist temporary permit issued under OAR 848-010-0026(1)(a) shall be authenticated by the permit holder and by a supervising physical therapist. (14) Documentation by a person who holds a physical therapist assistant temporary permit issued under OAR 848-010-0026(1)(a) shall be authenticated by the permit holder and by a supervising physical therapist or supervising physical therapist assistant. (15) For purposes of the Board's enforcement of these rules, patient records shall be kept for a minimum of seven years measured from the date of the most recent entry. Statutory/Other Authority: ORS 688.160 Statutes/Other Implemented: ORS 688.160, 688.010 & 688.210 History: OBPT 1-2025, amend filed 01/23/2025, effective 03/01/2025 PTLB 3-2018, amend filed 08/16/2018, effective 09/01/2018 PTLB 2-2013, f. 11-26-13, cert. ef. 1-1-14 PTLB 1-2007, f. 3-13-07, cert. ef. 4-1-07 PTLB 8-2005, f. 12-29-05, cert. ef. 1-1-06 PTLB 6-2004, f. & cert. ef. 12-29-04