Effective 28 Aug 2008

334.602. Patient record documentation requirements. — 1. Physical therapists and physical therapist assistants shall provide documentation in order that an adequate and complete patient record can be maintained. All patient records shall be legible and available for review and shall include at a minimum documentation of the following information:

(1) Identification of the patient, including name, birth date, address, and telephone number;

(2) The date or dates the patient was seen;

(3) The current status of the patient, including the reason for the visit;

(4) Observation of pertinent physical findings;

(5) Assessment and clinical impression of physical therapy diagnosis;

(6) Plan of care and treatment;

(7) Documentation of progress toward goals;

(8) Informed consent;

(9) Discharge summary.

2. Patient records remaining under the care, custody, and control of the licensee shall be maintained by the licensee of the board, or the licensee's designee, for a minimum of seven years from the date of when the last professional service was provided.

3. Any correction, addition, or change in any patient record shall be clearly marked and identified as such, and the date, time, and name of the person making the correction, addition, or change shall be included, as well as the reason for the correction, addition, or change.

4. The board shall not obtain a patient medical record without written authorization from the patient to obtain the medical record or the issuance of a subpoena for the patient medical record.

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(L. 2008 S.B. 788)