(a) Written policies and procedures shall be developed and maintained by the person responsible for the service in consultation with other appropriate health professionals and administration. Policies shall be approved by the governing body. Procedures shall be approved by the administration and medical staff where such is appropriate.

(b) The responsibility and the accountability of the physical therapy service to the medical staff and administration shall be defined.

(c) Physical therapy shall be given only on the signed order of a person lawfully authorized to give such an order.

(d) When physical therapy is ordered, the patient shall be evaluated by the physical therapist and a treatment program shall be established to include the modalities, frequency and duration of treatments. This program and any modifications shall be approved by the person who signed the order for service.

(e) Signed notes shall be entered into the record each time physical therapy service has been performed.

(f) Progress notes shall be written and signed at least weekly by the physical therapist and summarized upon completion of the treatment program.

(g) Physical therapy service staff shall be involved in orientation and in-service training of hospital employees.

(h) There shall be written techniques for cleaning and culturing of hydrotherapy equipment.

(i) Procedures shall be established for outpatient treatment, home visits and referrals to appropriate community agencies.

(j) Periodically, an appropriate committee of the medical staff shall evaluate the services provided and make appropriate recommendations to the executive committee of the medical staff and administration.