Louisiana Administrative Code › Title 46 - PROFESSIONAL AND OCCUPATIONAL STANDARDS › Part LIV - Physical Therapy Examiners › Subpart 2 - Practice › Chapter 3 - Practice › Subchapter C - Supervised Practice › Section LIV-341 - Documentation Standards [Formerly Section 323]

Current through Register Vol. 50, No. 6, June 20, 2024
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.