Or. Admin. Code § 848-040-0130 - Standards For The Documentation Of An Initial Evaluation

Except as provided in subsection (5) of OAR 848-040-0125, the record of the initial evaluation shall include:

(1) Patient's full name, age and sex;

(2) Identification number, if appropriate;

(3) Referral source, including patient self-referral;

(4) Pertinent medical or physical therapy diagnoses, medications if not otherwise accessible in another part of the patient's medical record, history of presenting problem and current complaints and symptoms, including onset date;

(5) Prior or concurrent services related to the provision of physical therapy services;

(6) Any co-existing condition that affects either the goals or the plan of care;

(7) Precautions, special problems and contraindications;

(8) Subjective information (patient's knowledge of problem);

(9) Patient's goals (with family input or family goals, if appropriate). Goals may be as provided in an applicable IEP, IFSP, or other designated plan of care; and

(10) Appropriate objective testing results, including but not limited to:

(a) Critical behavior/cognitive status;

(b) Physical status (e.g., pain, neurological, musculoskeletal, cardiovascular, pulmonary);

(c) Functional status (for Activities of Daily Living, work, school, home or sport performance); and

(d) Interpretation of evaluation results.

Notes

Or. Admin. Code § 848-040-0130

PTLB 6-2004, f. & cert. ef. 12-29-04; PTLB 1-2007, f. 3-13-07, cert. ef. 4-1-07; PTLB 3-2017, amend filed 11/28/2017, effective 1/1/2018; OBPT 1-2025, amend filed 01/23/2025, effective 3/1/2025

Statutory/Other Authority: ORS 688.160

Statutes/Other Implemented: ORS 688.160, 688.010 & 688.210