Practice Alerts

Disclaimer: Practice guidelines provide licensees with general guidance to promote good practice. Law, rules and regulations, not guidelines, specify the requirements for practice and what may constitute professional misconduct.

Alert 15: Recordkeeping

Documenting the Provision of Services

Maintain written records related to all substantive contact with patients/clients, including:

  • Reason for initial contact, preliminary evaluation, and subsequent disposition.
  • Comprehensive evaluation of problem, including, if appropriate, reasons to support the recommended diagnosis.
  • Initial plan for service, including specific goals and the interventions related to each goal.
  • Dates of service and issues of significance/treatments during each contact, including specific actions to be taken, if relevant.
  • Discharge summary, including specific notation of any plans for future treatment and/or referral; circumstances under which a patient/client stops using services against your advice; or statement that you are leaving the agency or practice.
  • Any consultations with other professionals, including reason for consult and outcome, and patient/client's authorization to release information.
  • Provider's full name and appropriate designation, e.g., PT or PTA, and the date of the entry.

Maintaining Records

  • Maintain all paper and electronic patient/client records in a secure area accessible only to authorized persons and in a manner that lends itself to substantiating the records to be trustworthy and unalterable.
  • Be aware of retention requirements for patient/client records, including the period required by law, and plan to retain longer when deemed appropriate. Section 29.2(a)(3) of the Regents' Rules states that it is unprofessional conduct for a licensee to fail "to maintain a record for each patient/client which accurately reflects the evaluation and treatment of the patient/client. Unless otherwise provided by law, all patient/client records must be retained for at least six years. Obstetrical records and records of minor patients/clients must be retained for at least six years, and until one year after the minor patient/client reaches the age of 21 years."

Suggestions for Documenting Initial Evaluation

Documentation for the initial examination and evaluation/consultation should include:

  • History of the presenting problem, current complaints, and precautions (including onset date).
  • Pertinent diagnosis (if a diagnosis has been received) or recommended diagnosis and medical history.
  • Demographic characteristics including pertinent psychological, social and environmental factors.
  • Prior or concurrent services related to the current episode of physical therapy care.
  • Co-morbidities that may affect the prognosis.
  • Statement of the patient’s/client’s knowledge of the problem.
  • Anticipated goals of and expected outcomes for the patient/client.
  • Documentation (if appropriate) of status of systems (cardiopulmonary, integumentary, musculoskeletal, neuromuscular).
  • Documentation of selection and administration of appropriate tests and measures to determine patient/client status in relevant areas and documentation of findings.
  • Documentation of evaluation (a dynamic process in which the PT makes clinical judgments based on data gathered during the examination).
  • Documentation of recommended diagnosis.
  • Documentation of prognosis (determination of the level of optimal improvement that might be attained through intervention and the amount of time required to reach that level. Documentation must include anticipated goals, expected outcomes, and plan of care).

Suggestions for Documenting Services

Documentation of interventions or services provided should be done for every visit or encounter and should include:

  • Patient/client self-report(s) (as appropriate).
  • Identification of specific interventions provided, including frequency, intensity, duration and equipment, as appropriate.
  • Changes in patient/client status as they relate to the plan of care.
  • Adverse reaction to interventions, if any.
  • Factors that modify frequency or intensity of intervention and progression toward anticipated goals, including patient/client adherence to instructions or home programs.
  • Communication/consultation with providers/patients/clients/family/significant others.
  • When indicated, revision of plan of care as directly correlated with anticipated goals and expected outcomes, as documented.

Documentation of the summation of an episode of care should be done at discharge and should include:

  • Anticipated goals and expected outcomes that have been achieved or reasons why they were not achieved.
  • Current physical/functional status.
  • Discharge plan that includes home program, suggestions for additional services, recommendations for follow-up physical therapy care, family and caregiver training, and equipment provided (if appropriate)

Adapted from the APTA Guide to Physical Therapist Practice June 2003.

Section 29.2(b) of the Regents' Rules defines professional misconduct as including a failure by certain licensed professionals to comply with Section 18 of the Public Health Law, which addresses the records of health care consumers. Section 18(2)(e) of the Public Health Law allows a provider to impose a reasonable charge for all inspections and copies of records not exceeding the costs incurred by such provider. However, the reasonable charge for paper copies must not exceed seventy-five cents per page. Moreover, a qualified person must not be denied access to patient/client information solely because of inability to pay. The authority to interpret Public Health Law is vested with the New York State Department of Health. Further information can be received from the Access to Patient Information Coordinator, New York State Department of Health, OPMC, 150 Broadway, Suite 355, Albany, NY 12204-2719; 1-800-663-6114.

Section 29.1(b)(7) of the Regents' Rules states that it is unprofessional conduct for a licensee to fail to make available to a patient or client, upon request, copies of documents in the possession or under the control of the licensee which have been prepared and paid for by the patient/client. Most health care providers must make records available for inspection within 10 days. In a residential care facility, such as a nursing home, records must be made available to a patient/client within 24 hours.

Article 136 of Education Law is silent regarding the matter of PTs co-signing the notes of PTAs. In some instances, hospitals and long term care facilities have developed policies that require PTs to co-sign the notes of PTAs under their supervision. (It is within the authority of a health care agency to develop and enforce policies and procedures that exceed, but are not inconsistent with, state or federal requirements.)

Citations of Pertinent Law, Rules or Regulations:
Education Law, Section 6509(9) – unprofessional conduct
Public Health Law Section 18 – access to records
Regents Rules, Part 29.1(b)(7) – failure to provide records unprofessional conduct
Regents Rules, 29.2(a)(3) – failing to keep records
Regulations of the Department of Health, section 415.3(c)(a)(iv) – rights of patient/clients in residential care facilities
Last Updated: April 15, 2021