General Discussion - Changes to documentation by PTA

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Changes to documentation by PTA

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Category: Physical Therapy Professional Forum
Forum Name: General Discussion
Forum Description: General discussion for physical therapists, physical therapist assistants and other health care professionals.
URL: http://www.cyberpt.com/ptforum/forum_posts.asp?TID=1211
Printed Date: Apr 29 2024 at 12:49am
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Topic: Changes to documentation by PTA

Posted By: DCole
Subject: Changes to documentation by PTA
Date Posted: Feb 22 2013 at 9:14am

I have searched the internet and the IL practice act but cannot find an answer to this...

If during the course of treatment, a PTA identifies additional areas of concern/deficit, can the PTA add a diagnosis code to the treatment note?

If not, must the patient be seen and the subsequent documentation be performed by a PT in order to add said diagnoses to the POC?

This is irregardless of insurer.

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DCole

Replies:

Posted By: Ask a PT
Date Posted: Feb 25 2013 at 1:11pm

From my understanding, the physical therapist is the only professional that is able to make the determination of the diagnosis. The PT performs the evaluation, reassessment and interpretation. The PTA follows the plan of care of the PT. At our facility, the PT must perform the 2 week reassessment and monthly notes. The PTA is to communicate with the PT if the plan of care needs to be changed or modified. The PT will document any changes in the patient's chart as necessary.

I am not familiar with the rules and regulations in IL but here is the link to WI regulations: http://docs.legis.wisconsin.gov/code/admin_code/pt/5.pdf - http://docs.legis.wisconsin.gov/code/admin_code/pt/5.pdf