21 NCAC 48C .0102. RESPONSIBILITIES

(a)  A physical therapist must determine the patient care plan and the elements of that plan appropriate for delegation.

(b)  A physical therapist must determine that those persons acting under his or her supervision possess the competence to perform the delegated activities.

(c)  A physical therapist may delegate responsibilities to physical therapist assistants, including supervising PT or PTA students.

(d)  A physical therapist must enter and review chart documentation, reexamine and reassess the patient and revise the patient care plan if necessary, based on the needs of the patient.

(e)  A physical therapist must establish a discharge plan that includes a discharge summary for each patient.

(f)  The physical therapist must provide all therapeutic interventions that will require the physical therapist’s expertise, and may delegate to a physical therapist assistant or physical therapy aide the delivery of service to the patient when it is safe and effective for the patient.

(g)  A physical therapist's responsibility for patient care management includes first-hand knowledge of the health status of each patient and oversight of all documentation for services rendered to each patient, including awareness of fees and reimbursement structures.

(h)  A physical therapist must be immediately available directly or by telecommunication to a physical therapist assistant supervising a physical therapy aide or student engaging in patient care.

(i)  A physical therapist who is supervising a physical therapy aide or student must be present in the same facility when patient care is provided.

(j)  A physical therapist shall clinically supervise only that number of assistive personnel, including physical therapists assistants, physical therapy aides, and students completing clinical requirements, as the physical therapist determines is appropriate for providing safe and effective patient interventions at all times.

(k)  A physical therapist must reassess a patient every 60 days or 13 visits, whichever occurs first.

(l)  A physical therapist must document every evaluation and intervention or treatment including the following elements:

(1)           Authentication (signature and designation) by the physical therapist who performed the service;

(2)           Date of the evaluation or treatment;

(3)           Length of time of total treatment session or evaluation;

(4)           Patient status report;

(5)           Changes in clinical status;

(6)           Identification of specific elements of each intervention or modality provided.  Frequency, intensity, or other details may be included in the plan of care and if so, do not need to be repeated in the daily note;

(7)           Equipment provided to the patient; and

(8)           Interpretation and analysis of clinical signs and symptoms and response to treatment based on subjective and objective findings, including any adverse reactions to an intervention.

(m)  At the time of reassessment the physical therapist must document:

(1)           The patient's response to therapy intervention;

(2)           The patient's progress toward achieving goals; and

(3)           Justifications for continued treatment.

 

History Note:        Authority G.S. 90-270.24; 90-270.26; 90-270.31; 90-270.34;

Eff. December 30, 1985;

Amended Eff. July 1, 2013; December 1, 2006; August 1, 2002; August 1, 1998; January 1, 1991.