Or. Admin. Code § 848-040-0150 - Standards For The Documentation of Treatment Provided
(1) Except as provided in subsection (5) of
OAR 848-040-0125, the record of treatment for each patient visit shall include
at a minimum:
(a) Subjective status of
patient;
(b) Specific treatments,
information, and education provided;
(c) Objective data from tests and
measurements conducted;
(d)
Assessment of the patient's response to treatment, including but not limited
to:
(A) Patient status, progression or
regression;
(B) Changes in
objective and measurable findings as they relate to existing goals;
and
(C) Adverse reactions to
treatment.
(e) Changes
in the plan of care.
(2)
When treatment is provided by a physical therapist assistant, the physical
therapist assistant shall record and authenticate those services. If the
supervising physical therapist records and authenticates treatment provided by
the physical therapist assistant, the physical therapist shall document which
services were provided that day by the physical therapist assistant. When
treatment is provided or assisted by an aide, the aide may only document in the
patient record[s] objective information about the treatment provided by the
aide. When a supervising physical therapist assistant or supervising physical
therapist authenticates treatment provided by an aide, the therapist shall
document which services were provided that day by the aide.
Notes
Statutory/Other Authority: ORS 688.160
Statutes/Other Implemented: ORS 688.160, 688.010 & 688.210
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