(A) A physical therapist is responsible for the physical therapy record of a patient.

(B) Only a licensed physical therapist or physical therapist assistant, provisional licensed physical therapist or physical therapist assistant, or student physical therapist or physical therapist assistant shall document in a physical therapy record.

(C) A physical therapy record consists of:

(1) the initial evaluation which is a written report signed and dated by the physical therapist performing the evaluation. An initial evaluation by a provisional licensed physical therapist must be reviewed, cosigned, and dated by the on-site supervising physical therapist;

(2) a plan of care developed by a licensed physical therapist, including:

(a) treatment to be rendered;

(b) frequency and duration of treatment;

(c) measurable goals.

(3) clinical notes that must be signed and dated by the person rendering treatment. All clinical notes written by a physical therapist student or physical therapist assistant student are to be reviewed, cosigned, and dated by the physical therapist or physical therapist assistant who is supervising the appropriate level student. Clinical notes written by a provisional physical therapist or a physical therapist assistant licensee must be reviewed, cosigned, and dated by the on-site supervising physical therapist every eighth treatment day or every sixty calendar days, whichever comes first;

(4) a discharge note which is a statement of the patient's status at the last treatment session as written, signed, and dated by the physical therapist or physical therapist assistant rendering service. All discharge notes written by a physical therapist student, physical therapist assistant student, and provisional licensed physical therapist or physical therapist assistant are to be reviewed, cosigned, and dated by the supervising physical therapist.

HISTORY: 1998 Act No. 360, Section 1.