Oregon Administrative Rules › Chapter 848 - OREGON BOARD OF PHYSICAL THERAPY › Division 40 - MINIMUM STANDARDS FOR PHYSICAL THERAPY PRACTICE AND RECORDS › Section 848-040-0110 - General Standards for Record Keeping

Current through Register Vol. 63, No. 7, July 1, 2024
(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) A
			 record shall be prepared on the date a physical therapy service is
			 provided.
(3) The permanent record
			 shall contain information for every physical therapy service provided, the date
			 the service was provided and the date the entry was made in the record. The
			 permanent record of a physical therapy service shall be prepared within seven
			 calendar days of the date the service was provided.
(4) The licensee who performs the physical
			 therapy service shall authenticate the permanent record 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 a
			 record 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
			 permanent patient record for authentication by the treating licensee. The
			 requirement for authentication shall not apply to records not related to
			 physical therapy treatment.
(6)
			 Either the permanent record or a record prepared on the date of service 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
			 recognized standard physical therapy abbreviations or are approved for use in
			 the specific practice setting.
(9)
			 When an error in the permanent 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 permanent 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