Documenting the Provision of Services

Guideline 3: Documenting the Provision of Services

3.1

Maintain written records for every visit or encounter with clients. Entries should be written in ink and signed by the licensee using full name and professional designation (e.g., PT or PTA) and date of service as well as:

1. Reason for encounter, preliminary assessment, and subsequent disposition.
2. Comprehensive evaluation of problem, including the interpretation of tests and measurements, to determine intervention and assist in the diagnosis and prognosis.
3. Plan for service, including specific goals and the interventions related to each goal. If actions are delegated to another licensed professional, specify those tasks and how the patient’s progress will be assessed or reviewed. If plan is modified this should be noted along with recommendations for follow-up or other intervention.
4. Date of service and intervention or treatment provided during each contact with client, including specific follow-up actions to be taken, if relevant.
5. Discharge summary, including specific notation of any plans for future interventions, home care program, training of caregivers or equipment provided.
6. In the event of a referral to another provider or circumstances under which a client stops using services against your advice or because you are leaving the agency and/or practice, the note should include recommended actions.
7. Any consultations with other professionals, including reason for consultation and outcome, and client’s authorization to release information.
8. Education Law is silent regarding the matter of PTs co-signing the notes of PTAs. However, because PTs are responsible for the evaluation, testing, interpretation, planning, and modification of patient programs, it is not uncommon for them to co-sign PTA notes as an indication that they are aware of the actions of PTAs in relation to their plan. Indeed, 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 state or federal requirements.)
9. Education law does not require that a licensed physical therapist co-sign the notes of a student, limited permittee or other licensee. The required supervision of a student, limited permittee or physical therapist assistant may be verified through clear documentation of the physical therapist’s review of patient progress and changes in the treatment plan. However, insurance companies and other third-party payers may require a co-signature for reimbursement.

3.2

Maintain all paper and electronic 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.

3.3

In the event a record must be corrected or changed, line through, initial and date the change, and note the reason in a separate entry. Do not obliterate or destroy the original entry.

3.4

Be aware of retention requirements for client records, including the period required by law and requirements and allowed fees for providing patient access to records. All patient records must be retained for at least six years. Obstetrical records and records of minor patients must be retained for at least six years, and until one year after the minor patient reaches the age of 21 years. However, insurers, Medicaid, Medicare, or employers may have more stringent requirements that you should know.

3.5

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. "Standards of Practice" may not limit access to records since such access is guaranteed by the previously cited provision. Records must be available for inspection within 10 days for a health care provider or 24 hours for a nursing home.

3.6

Institutions or employers may establish policies that are more stringent or explicit than Education Law and regulations but the licensed professional is responsible for conforming with applicable law.

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Citations of Pertinent Law, Rules or Regulations:
Education Law, Section 6509(9) - "unprofessional conduct"
Education Law, Section 6731(a) – "definition of physical therapy"
Public Health Law, Section 18 - "access to records"
Regents Rule, Part 29.2(a)(3) – "failing to keep records"
Regents Rule, Part 29.1(b)(7) – "failing to make records available"