North Carolina Administrative Code › Title 21 - OCCUPATIONAL LICENSING BOARDS AND COMMISSIONS › Chapter 48 - PHYSICAL THERAPY EXAMINERS › Subchapter C - SCOPE OF PHYSICAL THERAPY PRACTICE › Section .0100 - PHYSICAL THERAPISTS › Section 48C .0102 - RESPONSIBILITIES

Current through Register Vol. 39, No. 2, July 15, 2024
(a) A physical
				  therapist shall determine the patient care plan and the elements of that plan
				  appropriate for delegation.
(b) A
				  physical therapist shall determine that those persons acting under his or her
				  supervision possess the competence to perform the delegated
				  activities.
(c) A physical
				  therapist may delegate responsibilities to physical therapist assistants,
				  including supervising physical therapist or physical therapist assistant
				  students.
(d) A physical therapist
				  shall enter and review chart documentation, reexamine and reassess the patient,
				  and revise the patient care plan if necessary, based on the needs of the
				  patient.
(e) A physical therapist
				  shall establish a discharge plan that includes a discharge summary or episode
				  of care for each patient.
(f) The
				  physical therapist shall provide all therapeutic interventions that require the
				  physical therapist's expertise, and may delegate to a physical therapist
				  assistant or physical therapy aide the delivery of service to the patient when
				  it is safe and effective for the patient.
(g) A physical therapist's responsibility for
				  patient care management includes first-hand knowledge of the health status of
				  each patient and oversight of all documentation for services rendered to each
				  patient, including awareness of fees and reimbursement structures.
(h) A physical therapist shall be immediately
				  available in person or by telecommunication to a physical therapist assistant
				  supervising a physical therapy aide or student engaging in patient
				  care.
(i) A physical therapist who
				  is supervising a physical therapy aide or student shall be present in the same
				  facility when patient care is provided.
(j) A physical therapist shall clinically
				  supervise only that number of assistive personnel, including physical therapist
				  assistants, physical therapy aides, and students completing clinical
				  requirements, as the physical therapist determines is appropriate for providing
				  safe and effective patient interventions at all times.
(k) If a physical therapist assistant or
				  physical therapy aide is involved in the patient care plan, a physical
				  therapist shall reassess a patient every 60 days or 13 visits, whichever occurs
				  first.
(l) A physical therapist
				  shall document every evaluation and intervention or treatment including the
				  following elements:
(1) authentication
				  (signature and designation) by the physical therapist who performed the
				  service;
(2) date of the evaluation
				  or treatment;
(3) length of time of
				  total treatment session or evaluation;
(4) patient status report;
(5) changes in clinical status;
(6) identification of specific elements of
				  each intervention or modality provided. Frequency, intensity, or other details
				  may be included in the plan of care and if so, do not need to be repeated in
				  the daily note;
(7) equipment
				  provided to the patient; and
(8)
				  interpretation and analysis of clinical signs, symptoms, and response to
				  treatment based on subjective and objective findings, including any adverse
				  reactions to an intervention.