The Board requires documentation of EACH treatment session; in other words, there should be an entry for every visit or encounter between the patient and the PT or PTA, regardless of how many times in a day or a week the patient is seen. Each entry needs to be physically or electronically signed by the person who sees/treats the patient, and If the interaction is between the PTA and the patient, the name of the PT who is supervising at the time of the interaction must be included in each entry. Medicare requirements for weekly progress notes do not change this requirement, nor do limitations of electronic documentation systems. If you cannot make an entry for each treatment session, and include all the information required by the Board, you are practicing in violation of the rules.
Whether you document on paper or electronically, you should write your note promptly. Prompt documentation ensures accuracy, and protects you as well as the patient. Missing, inaccurate, or delayed documentation can result in disciplinary action if a complaint is filed against you. Additionally, you should be aware of the documentation requirements that are specific to different payers, settings, or your employer/organization. A good resource on the components of documentation is APTA’s Defensible Documentation.
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