Ariz. Admin. Code § R4-24-304 - Adequate Patient Records

A. A physical therapist shall ensure that a patient record meets the following minimum standards:

1. Each entry in the patient record is:

a. Legible,

b. Accurately dated, and

c. Signed with the name and legal designation of the individual making the entry;

2. If an electronic signature is used to sign an entry, the electronic signature is secure;

3. The patient record contains sufficient information to:

a. Identify the patient on each page of the patient record,

b. Justify the therapeutic intervention,

c. Document results of the therapeutic intervention,

d. Indicate advice or cautionary warnings provided to the patient,

e. Enable another physical therapist to assume the patient's care at any point in the course of therapeutic intervention, and

f. Describe the patient's medical history.

4. If an individual other than a physical therapist or physical therapist assistant makes an entry into the patient record, the supervising physical therapist co-signs the entry;

5. If it is determined that erroneous information is entered into the patient record:

a. The error is corrected in a manner that allows the erroneous information to remain legible, and

b. The individual making the correction dates and initials the correct information; and

6. For each date of service there is an accurate record of the physical therapy services provided and billed.

B. Initial evaluation. As required by A.R.S. § 32-2043(F)(1), a physical therapist shall perform the initial evaluation of a patient. The physical therapist who performs an initial evaluation shall make an entry that meets the standards in subsection (A) in the patient record and document:

1. The patient's reason for seeking physical therapy services;

2. The patient's relevant medical diagnoses or conditions;

3. The patient's signs and symptoms;

4. Objective data from tests or measurements;

5. The physical therapist's interpretation of the results of the examination;

6. Clinical rationale for therapeutic intervention;

7. A plan of care that includes the proposed therapeutic intervention, measurable goals, and frequency and duration of therapeutic intervention; and

8. The patient's prognosis.

C. Therapeutic-intervention notes. For each date that a therapeutic intervention is provided to a patient, the individual who provides the therapeutic intervention shall make an entry that meets the standards in subsection (A) in the patient record and document:

1. The patient's subjective report of current status or response to therapeutic intervention;

2. The therapeutic intervention provided or appropriately supervised;

3. Objective data from tests or measures, if collected;

4. Instructions provided to the patient, if any; and

5. Any change in the plan of care required under subsection (B)(7).

D. Re-evaluation. As required by A.R.S. § 32-2043(F)(2), a physical therapist shall perform a re-evaluation when a patient fails to progress as expected, progresses sufficiently to warrant a change in the plan of care, or in accordance with R4-24-303(F)(4). A physical therapist who performs a re-evaluation shall make an entry that meets the standards in subsection (A) in the patient record and document:

1. The patient's subjective report of current status or response to therapeutic intervention;

2. Assessment of the patient's progress;

3. The patient's current functional status;

4. Objective data from tests or measures, if collected;

5. Rationale for continuing therapeutic intervention; and

6. Any change in the plan of care required under subsection (B)(7).

E. Discharge summary. As required by A.R.S. § 32-2043(F)(3), a physical therapist shall document the conclusion of care in a patient's record regardless of the reason that care is concluded.

1. If care is provided in an acute-care hospital, the entry made under subsection (C) on the last date that a therapeutic intervention is provided constitutes documentation of the conclusion of care if the entry is made by a physical therapist.

2. If care is not provided in an acute-care hospital or if a physical therapist does not make the entry under subsection (C) on the last date that a therapeutic intervention is provided, a physical therapist shall make an entry that meets the standards in subsection (A) in the patient record and document:

a. The date on which therapeutic intervention terminated;

b. The reason that therapeutic intervention terminated;

c. Inclusive dates for the episode of care being terminated;

d. The total number of days on which therapeutic intervention was provided during the episode of care;

e. The patient's current functional status;

f. The patient's progress toward achieving the goals in the plan of care required under subsection (B)(7); and

g. The recommended discharge plan.

Notes

Ariz. Admin. Code § R4-24-304

New Section adopted by final rulemaking at 6 A.A.R. 2399, effective June 9, 2000 (Supp. 00-2). R4-24-304 renumbered to R4-24-305; new Section R4-24-304 made by final rulemaking at 14 A.A.R. 3418, effective October 4, 2008 (Supp. 08-3).