6. Can a PTA update short term goals (STG) as long as the supervising PT modifies the long term goals (LTG)?
No, the Board does not make any distinction in Rule as to whether or not a goal is short term or long term. Section 322.2 (b) (3) (B) of the PT Rules states that the PTA may not alter a plan of care or goals. Furthermore, §322.1 (c) (4) states that “The plan of care […]
5. Does a HCPC code with therapy minutes and the name of the PT or PTA (and the name of the supervising PT) suffice as a daily treatment note?
No. At a minimum, a daily treatment note should include the patient’s name, the date, a description of the intervention and modalities, along with treatment minutes that were provided, in language that supports the CPT codes that you’re billing. Each entry needs to be physically or electronically signed by the licensee who sees/treats the patient. […]
4. How many conferences should we have for each patient? Is there a frequency?
The rules leave the decision regarding frequency to the professional judgment of the PT. The PT’s decision should be based on the condition of the patient, the practice setting, the experience and abilities of the PTA, and so on. Not all patients or PTAs will require the same number or frequency of conferences. The Board […]
3. Must a PTA have notes co-signed?
No. However, the name of the supervising PT must be included in the note in some form. See the Board rules, §322.1(d)
2. Do the rules require that a plan of care be certified by the referring practitioner?
The board’s rules do not require the referring practitioner to sign the plan of care, nor do the rules address when a referral source needs to approve continuation of services. If a referral does not specifically address duration or frequency of treatment, it is up to the PT’s professional judgment how often to notify the […]
1. How often do I need to document treatment?
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 […]