Section 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

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 phys- ical 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 thera- peutic intervention is provided constitutes documentation of the conclusion of care if the entry is made by a physi- cal therapist.

2.        If care is not provided in an acute-care hospital or if a physical therapist does not make the entry under subsec- tion (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 termi- nated;

b.        The reason that therapeutic intervention terminated;

c.         Inclusive dates for the episode of care being termi- nated;

d.        The total number of days on which therapeutic inter- vention 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.

Historical Note

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).