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.

Last Updated

Jun. 8, 2021

Rule 848-040-0150’s source at or​.us