OAR 848-040-0150
Standards For The Documentation of Treatment Provided

(1)

Except as provided in subsection (5) of OAR 848-040-0125 (Standards For Initiation Of Physical Therapy), the record of treatment for each patient visit shall include at a minimum:

(a)

Subjective status of patient;

(b)

Specific treatments, information, and education provided;

(c)

Objective data from tests and measurements conducted;

(d)

Assessment of the patient’s response to treatment, including but not limited to:

(A)

Patient status, progression or regression;

(B)

Changes in objective and measurable findings as they relate to existing goals; and

(C)

Adverse reactions to treatment.

(e)

Changes in the plan of care.

(2)

When treatment is provided by a physical therapist assistant, the physical therapist assistant shall record and authenticate those services. If the supervising physical therapist records and authenticates treatment provided by the physical therapist assistant, the physical therapist shall document which services were provided that day by the physical therapist assistant. When treatment is provided or assisted by an aide, the aide may only document in the patient record[s] objective information about the treatment provided by the aide. When a supervising physical therapist assistant or supervising physical therapist authenticates treatment provided by an aide, the therapist shall document which services were provided that day by the aide.

Source: Rule 848-040-0150 — Standards For The Documentation of Treatment Provided, https://secure.sos.state.or.us/oard/view.action?ruleNumber=848-040-0150.

848–040–0100
Definitions 848–040–0105
General Standards for Practice 848–040–0110
General Standards for Record Keeping 848–040–0117
Standards For Authorization To Provide Physical Therapy Services 848–040–0120
Standards For Record Of Authorization 848–040–0125
Standards For Initiation Of Physical Therapy 848–040–0130
Standards For The Documentation Of An Initial Evaluation 848–040–0135
Standards For The Plan of Care 848–040–0140
Standards For The Documentation Of The Plan Of Care 848–040–0145
Standards For Providing Treatment 848–040–0147
Standards for Treatment by a Student PT or Student PTA 848–040–0150
Standards For The Documentation of Treatment Provided 848–040–0155
Standards For Performing a Reassessment 848–040–0160
Standards For The Documentation of a Reassessment 848–040–0165
Standards For Discharging A Patient From Therapy 848–040–0170
Standards For Discharge Records 848–040–0175
Standards for Screening Services 848–040–0180
Standards for Telehealth Services 848–040–0190
Standards for Community Education, Prevention, Health Promotion and Wellness Services

Last Updated

Jun. 8, 2021

Rule 848-040-0150’s source at or.us

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Location: https://oregon.public.law/rules/oar_848-040-0150

Original Source: Rule 848-040-0150 — Standards For The Documentation of Treatment Provided, https://secure.sos.state.or.us/oard/view.action?ruleNumber=848-040-0150 (last accessed Jun. 8, 2021).