Documentation Guidelines for Physical Therapy Assistants

Most physical therapy assistants have associate degrees.
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Being a physical therapy assistant is a hands-on job -- teaching and supervising exercise, stretching muscles, positioning patients -- and then, when you’re done, there’s the inevitable paperwork. Since you’re not an independent practitioner, you must follow some strict guidelines when you document your patient care.

Some of the Basics

    Physical therapist assistants, or PTAs, work under the supervision of physical therapists. Unless you practice in Hawaii, you’ll need a license or certification. Each state makes its own rules about what kind of education a PTA needs, whether they must be certified as well as or instead of licensed and what they can do. PTAs typically help patients exercise, observe their progress and report to the physical therapist. They may also use a variety of devices or equipment in their work. The PTA must document all of these activities, as well as the patient’s response to therapy and other relevant observations.

Ground Rules

    The American Physical Therapy Association has written documentation guidelines that affect all PTAs. Many of these are basic, such as the rule that whatever the PTA did must be documented, dated and signed by the PTA who actually performed the treatment. The APTA also gets into the details, such as with a requirement that all handwritten entries must be in ink and have an original signature. Electronic documentation must be properly authenticated by username and password. Documentation is also required each time a PTA sees a patient or if the patient is scheduled but cancels the appointment or simply doesn’t show up.

Do's and Don'ts

    When it comes to documentation, PTAs have a few do's and don’ts. In California, for example, one important "don’t" -- a PTA cannot perform the initial assessment of the patient, according to the Physical Therapy Board of California. Nor can a PTA collect data or perform measurements until the physical therapist has seen the patient and decided what tasks the PTA can perform. PTAs cannot write a discharge summary, document patient evaluations or develop a care plan. The PTA is not allowed to write progress notes that will be sent to another health care professional.

Supervision and Documentation

    Another issue related to documentation is the supervision required by state law. The Federation of State Boards of Physical Therapy notes that, in a hospital outpatient rehab setting, state law takes precedence over Medicare regulations. In the outpatient setting in private practice, however, Medicare requires the physical therapist to be onsite and provide direct supervision for the PTA to perform any functions, including documentation. Some insurance companies may also have rules that govern issues of supervision and documentation, according to the Federation of State Boards of Physical Therapy.

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