Recordkeeping and Supervision in a Physical Therapy Practice

(The following blog post will also appear in PT Interventions, the semi-annual, members-only, newsletter of the California Physical Therapy Association.)
As physical therapy professionals know by now, the Physical Therapy Board of California (“Board”) issued new regulations on medical recordkeeping and supervision of assistive personnel, which became effective July 14, 2011.[i] A year and a half later, some of the issues addressed in these regulations, such as whether or not physical therapy aides (“PT aides”) may record notes in the medical records, remain unclear.

History

In 1983, the Board established a regulation that required a supervising physical therapist to be on the premises with a physical therapy assistant (“PTA”) 50% of the work day. In 1993, the Board modified this language eliminating the 50% while emphasizing the physical therapist’s responsibility to ensure the PTA does not function autonomously. As the result of the Board recognizing that the regulation was not clear regarding the responsibility for patient care provided by the PTA, the Board appointed a task force to study the issue. As a result of this task force, the Board launched the rulemaking regulatory process in 2010 which gave rise to the 2011 regulations.
Types of Assistive Personnel
The Board’s regulations contemplate five types of assistive personnel in a physical therapy practice. They include PTAs, PT aides, students and interns, and PTA applicants and physical therapist license applicants. In addition to defining the tasks that each of these providers may perform, the regulations also outline the level of physical therapist supervision required and what must go into the medical record.
Physical Therapy Students and Interns
These students and interns may provide assigned patient care under the supervision of a physical therapist that is on site.[ii] Students and interns must chart in the record and sign the chart entry but the supervising physical therapist must countersign the chart the same day as patient-related tasks are provided.[iii] For PTA students or interns, the supervising physical therapist must also conduct and record a weekly chart review called a “case conference” in the regulations.[iv]
Physical Therapist License Applicants
A physical therapist whose application has been filed and reviewed by the Board may perform physical therapy services under the direct and immediate supervision of a physical therapist.[v] This means the physical therapist must be in “close proximity to the location where the …applicant is rendering …treatment.”[vi] The Board’s regulations provide that the physical therapist license applicant must record treatment in the record and sign the record and the supervising physical therapist must countersign the record on the same day as patient-related tasks were provided.[vii] The physical therapist supervising such an applicant must also document in the medical record the letter from the Board indicating “applicant status” and the expiration date.[viii]
Physical Therapy Assistant License Applicants
The regulation regarding supervising PTA license applicants contains nearly identical requirements to those for supervising a physical therapist license applicant.[ix] The only additional requirement is that the supervising physical therapist “will conduct a weekly case conference and document it in the patient record.”[x]
Physical Therapy Assistants
As licensed personnel, these providers have less direct supervision than PT aides and student, but as the regulations make clear, the physical therapist is responsible for “all physical therapy services” provided by the PTA.[xi] The section specifically prohibits the PTA from functioning autonomously and requires the physical therapist to follow the patient’s progress and to maintain responsibility for elements of treatment a PTA may perform.[xii]
In addition, the regulations assign the physical therapist who performs the initial evaluation as the “physical therapist of record” until there is a “reassignment” to another therapist. The physical therapist of record must ensure that the organization has a written policy that outlines the “system of transfer.”[xiii]
The PTA must also be able to communicate with the physical therapist of record at all times during the treatment.[xiv]  The Board’s regulation also prescribes certain physical therapist tasks that a PTA may not perform such as:

1. measurement or data collection prior to evaluation of the patient;
2. documenting patient evaluations or reevaluations;
3. establishing or changing a plan of care
4. preparing a discharge summary;
5. writing non-chart note summaries to other professionals;
6. being the sole physical therapy representative in any meeting with other health are professionals assessing or modifying patient care;
7. supervising a PT Aide;
8. providing treatment if the PTA has a management position in the physical therapy practice.[xv]
9. A PTA shall document treatment of a patient and sign the patient record much like a physical therapist documents treatment.[xvi]

 
Physical Therapy Aides
PT aides are unlicensed and have the strictest requirements for supervision. To even utilize the services of a PT aide, the regulations require the physical therapist, prior to the aide providing patient care, to:

1. evaluate and document the aide’s competency for providing the patient related task; and
2. make the record available to the Board or any physical therapist utilizing that aide upon request.[xvii]

 
The regulations permit PT aides to perform both “patient related tasks” and “non-patient related tasks” both under the direct supervision of a physical therapist.[xviii] And not surprisingly, the Board has prescribed the most strict supervision requirement of all assistive personnel for PT Aides:

The physical therapist shall provide continuous and immediate supervision of the aide. The physical therapist shall be in the same facility as the aide and in immediate proximity to the location where the aide is performing patient related tasks. The physical therapist shall be readily available at all times to provide immediate advice, instruction or intervention in the care of the patient. When patient related tasks are provided to a patient by an aide the physical therapist shall at some point during the treatment day provide direct service to the patient as treatment for the patient’s condition or to further evaluate and monitor the patient’s progress.[xix]

But while the Board has specifically spelled out its requirements for supervising PT aides and what types of task they may perform, the Board’s Regulation section 1399, entitled “Requirements for Use of Aides,” is silent regarding the role of aides in medical record-keeping.
The Role of Physical Therapy Aides in Charting
Whether or not PT aides may chart any types of treatment in patient records has been an issue of much discussion. Despite the changes to the Board’s regulations to make things more clear, this issue is not specifically addressed.
The Board’s regulation on patient records provides all of the things a physical therapist must document and sign in the patient record. In addition, the regulation makes clear that the physical therapist has to ensure compliance with assistive personnel in documenting their treatment in the record[xx] and that the physical therapist is responsible for documenting and signing his or her treatments and those provided by a PT aide.[xxi] These requirements are consistent with the physical therapists’ overall responsibility for treatment of patients. But can a PT aide participate in the documentation or write in the patient charts as long as the physical therapist documents as well?
The California Physical Therapy Association (“CPTA”) tried to clarify this issue with the Board. On July 24, 2012, Ms. Sarah Conley of the Board’s Administrative Services Section responded as follows:

The Physical Therapy Board of California (Board) received your inquiry regarding whether physical therapy aides are permitted to document and make notations in the patient record with a co-signature of the supervising physical therapist. Since the Board President sets the agenda for the Board and she determined a suitable response could be prepared by staff, it was decided not to place your inquiry on the Board agenda. However, the Board is aware of this concern and staff is conducting further research before proving a response.

Once a determination has been made, you will be notified in writing.

At the time this article was drafted at the end of January 2013, CPTA has received no response.
What to Do
As with many areas of the law and in the regulatory arena, the Board’s regulations neither seem to prohibit PT aides from charting nor expressly authorize them to do so. In fact, the regulations do not directly address the issue.
Accordingly, physical therapists are encouraged to make sure they are the ones involved in the charting of PT aides’ treatments and advised to seek the advice of experienced health care legal counsel regarding compliance with this issue.