(a) A physical therapist shall document and sign in the patient record the following in accordance with subsection (c):
(1) Examination and re-examination
(2) Evaluation and reevaluation
(4) Prognosis and intervention
(5) Treatment plan and modification of the plan of care
(6) Each treatment provided by the physical therapist or a physical therapy aide
(b) The physical therapist assistant shall document and sign in the patient record any treatment provided by that individual, in accordance with subsection (c).
(c) With respect to any care provided to the patient, the patient record shall indicate:
(1) The date and nature of the service provided and
(2) The name and title of any individual who provided such service, including the individual's role in that service. As used in this section, the term “service” does not include “non-patient related tasks” as defined in section 1399.
(d) The physical therapist shall ensure compliance with subsection (c).
(e) The requirements of this section are in addition to the requirements of the following sections:
(1) 1398.37(d) [relating to physical therapist students],
(2) 1398.44(e)(1) [relating to physical therapist assistants]
(3) 1398.52(d) [relating to physical therapist assistant students]
(4) 1399.10 [relating to physical therapist license applicants]; and
(5) 1399.12 [relating to physical therapist assistant license applicants].
(f) Electronic signatures are sufficient for purposes of this section.
Credits
Note: Authority cited: Section 2615, Business and Professions Code. Reference: Section 2620.7, Business and Professions Code.
1. Renumbering and amendment of former section 1399.85 to new section 1398.13 filed 6-14-2011; operative 7-14-2011 (Register 2011, No. 24).
2. Change without regulatory effect amending subsection (e)(1) filed 9-21-2015 pursuant to section 100, title 1, California Code of Regulations (Register 2015, No. 39).
This database is current through 6/21/24 Register 2024, No. 25.
Cal. Admin. Code tit. 16, § 1398.13, 16 CA ADC § 1398.13
