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PHYSICAL THERAPIST LICENSING BOARD
DIVISION 40
MINIMUM STANDARDS FOR PHYSICAL THERAPY PRACTICE AND RECORDS
848-040-0100
Definitions
As used in this Division:
(1) "Authentication" means
the process by which the licensee reviews and validates the accuracy of the record
entry. By authenticating a record entry, the licensee certifies that the services
described were performed by the authenticating licensee or performed by a person
under that licensee's supervision.
(2) “IDEA” means
Individuals with Disabilities Education Improvement Act.
(3) "IEP" means an Individualized
Education Plan developed for a child/student qualified under the IDEA program.
(4) "IFSP" means an Individualized
Family Services Plan developed for a child qualified under the IDEA Early Intervention
Program.
(5) "Licensee" means a physical
therapist or a physical therapist assistant and includes a temporary permit holder.
(6) "Patient" means one who
seeks and receives physical therapy services. For purposes of these rules, patient
may include a person receiving services in a home or clinical setting, a student
in a school setting, a child receiving early intervention services, a resident of
a care facility, or an animal.
(7) "Permanent Record" means
the final version of the record of each evaluation, reassessment or treatment provided
to a patient which becomes part of the patient's medical record.
(8) “Physical therapy
intervention” means a treatment or procedure and includes but is not limited
to: therapeutic exercise; gait and locomotion training; neuromuscular reeducation;
manual therapy techniques (including manual lymphatic drainage, manual traction,
connective tissue and therapeutic massage, mobilization/manipulation of soft tissue
or spinal or peripheral joints, and passive range of motion); functional training
related to physical movement and mobility in self-care and home management (including
activities of daily living (ADL) and instrumental activities of daily living (IADL));
functional training related to physical movement and mobility in work (job/school/play),
community, and leisure integration or reintegration (including IADL, work hardening,
and work conditioning); prescription, application, and, as appropriate, fabrication
of devices and equipment (assistive, adaptive, orthotic, protective, or supportive);
airway clearance techniques; integumentary repair and protective techniques; electrotherapeutic
modalities; physical agents and mechanical modalities; and patient related instruction
and education.
(9) "Plan of care" means
a written course of physical therapy treatment established by a physical therapist
following an initial evaluation which integrates the evaluation data collected to
determine the degree to which physical therapy interventions are likely to achieve
anticipated goals and expected outcomes.
(10) "Record" means a written
account of the detailed information gathered from each evaluation, reassessment,
and the treatment provided to a patient. This documentation may be used to create
the separate, permanent record, or it may serve as the permanent record.
(11) "Student" means a child
ages 3 to 21 who are enrolled in an educational institution and who qualifies for
services under IDEA or Section 504 of the Rehabilitation Act, or other designated
plan of care, or child ages 0-2 who qualifies under the IDEA Early Intervention
Program.
(12) “Student PT or
Student PTA” means a person enrolled in a CAPTE accredited physical therapist
or physical therapist assistant program and who is providing patient care as part
of the required clinical education.
(13) “Telehealth service”
means a physical therapy intervention, including assessment or consultation, that
can be safely and effectively provided using synchronous two-way interactive video
conferencing, or asynchronous video communication, in accordance with generally
accepted healthcare practices and standards. For purposes of these rules, “telehealth
service” also means, or may be referred to, as “telepractice, teletherapy,
or telerehab.”
(14) “Domiciled”
a person is domiciled in this state if the person’s place of abode is in the
state and the person intends to remain in the state or, if absent, to return to
it.
Stat. Auth.: ORS 688.160
Stats. Implemented: ORS 688.160,
688.010, 688.210
Hist.: PTLB 6-2004, f. &
cert. ef. 12-29-04; PTLB 1-2007, f. 3-13-07, cert. ef. 4-1-07; PTLB 2-2008, f. 12-16-08,
cert. ef. 1-2-09; PTLB 1-2010, f. 2-16-10, cert. ef. 3-1-10; PTLB 2-2015, f. 8-27-15,
cert. ef. 9-1-15
848-040-0105
General Standards for Practice
(1) Licensees shall practice competently.
A licensee practices competently when the licensee uses that degree of care, skill
and diligence that would be used by a reasonable, careful and prudent licensee under
the same or similar circumstances.
(2) A physical therapist
must immediately refer a patient to an appropriate medical provider if signs or
symptoms are present that require treatment or diagnosis by such provider or for
which physical therapy is contraindicated or if treatment for the signs or symptoms
is outside the knowledge of the physical therapist or scope of practice of physical
therapy.
(3) A licensee shall not
delegate to another person any task that the person is not legally authorized to
perform or is not qualified by training and experience to perform.
(4) A licensee shall not
provide treatment intervention that is not warranted by the patient's condition.
(5) A licensee shall respect
the privacy and dignity of the patient in all aspects of practice.
(6) A licensee shall comply
with the laws and rules governing the use and disclosure of a patient's protected
health information as provided in ORS 192.553-192.581.
(7) A licensee shall comply
with the provisions of ORS 688.135(3) by displaying a copy of their current license
in their place(s) of employment in a location accessible to public view, or by making
a paper or electronic copy readily available upon request, or by displaying an electronic
verification of current status from the Board’s website.
Stat. Auth.: ORS 688.160
Stats. Implemented: ORS 688.160,
688.010 & 688.210
Hist.: PTLB 6-2004, f. &
cert. ef. 12-29-04; PTLB 8-2005, f. 12-29-05, cert. ef. 1-1-06; PTLB 2-2013, f.
11-26-13, cert. ef. 1-1-14
848-040-0110
General Standards for Record Keeping
(1) The licensee who performs the physical
therapy service shall prepare a complete and accurate record for every patient,
regardless of whether compensation is given or received for the therapy services
and regardless of whether the patient receives treatment pursuant to a referral
or is self-referred.
(2) A record shall be prepared
on the date a physical therapy service is provided.
(3) The permanent record
shall contain information for every physical therapy service provided, the date
the service was provided and the date the entry was made in the record. The permanent
record of a physical therapy service shall be prepared within seven calendar days
of the date the service was provided.
(4) The licensee who performs
the physical therapy service shall authenticate the permanent record of the service
that was performed. Authentication may be made by written signature or by computer.
If authentication is by computer, the licensee shall not permit another person to
use the licensee's password to authenticate the entry. Authentication may not be
accomplished by the use of initials, except when a record entry identifying an error
is authenticated. A rubber stamp may not be used to authenticate any entry in a
patient record.
(5) Non-licensees, including
physical therapist aides, may prepare physical therapy treatment-related entries
for the permanent patient record for authentication by the treating licensee. The
requirement for authentication shall not apply to records not related to physical
therapy treatment.
(6) Either the permanent
record or a record prepared on the date of service shall be readily accessible to
a licensee prior to when that licensee provides subsequent treatment to the patient.
"Readily accessible" means the authenticating licensee is able to produce the record
immediately upon request.
(7) All entries shall be
legible and permanent handwritten records shall be in ink.
(8) Abbreviations may be
used if they are recognized standard physical therapy abbreviations or are approved
for use in the specific practice setting.
(9) When an error in the
permanent record is discovered, the error shall be identified and corrected. The
erroneous entry shall be crossed out, dated and initialed or otherwise identified
as an error in an equivalent written manner by the author of the erroneous entry.
(10) Late entries or additions
to entries in the permanent record shall be documented when the omission is discovered
with the following written at the beginning of the entry: "late entry for (date)"
or "addendum for (date)" and authenticated;
(11) Treatment provided by
a student physical therapist (SPT) may be documented either by the SPT or by the
supervising therapist. Documentation by a SPT shall be signed by the student and
authenticated by a supervising physical therapist.
(12) Treatment provided by
a student physical therapist assistant (SPTA) may be documented either by the SPTA
or by the supervising therapist or physical therapist assistant. Documentation
by a SPTA shall be signed by the student and authenticated by a supervising physical
therapist or supervising physical therapist assistant.
(13) Documentation by a person
who holds a physical therapist temporary permit issued under OAR 848-010-0026(1)(a)
or (1)(c) shall be authenticated by the permit holder and by a supervising physical
therapist.
(14) Documentation by a person
who holds a physical therapist assistant temporary permit issued under OAR 848-010-0026(1)(a)
shall be authenticated by the permit holder and by a supervising physical therapist
or supervising physical therapist assistant.
(15) For purposes of the
Board's enforcement of these rules, patient records shall be kept for a minimum
of seven years measured from the date of the most recent entry.
Stat. Auth.: ORS 688.160
Stats. Implemented: ORS 688.160,
688.010 & 688.210
Hist.: PTLB 6-2004, f. &
cert. ef. 12-29-04; PTLB 8-2005, f. 12-29-05, cert. ef. 1-1-06; PTLB 1-2007, f.
3-13-07, cert. ef. 4-1-07; PTLB 2-2013, f. 11-26-13, cert. ef. 1-1-14
848-040-0117
Standards For Authorization To Provide
Physical Therapy Services
As a result of legislative changes effective
January 1, 2014, a physical therapist is no longer required to limit treatment of
a self-referred patient to 60 days before having to refer the patient to a provider
identified in ORS 688.132(1).
(1) A physical therapist
may initiate and provide physical therapy to a patient who is either self-referred
or referred by a “provider of care”, defined in ORS 688.132 as a medical
doctor, osteopathic physician, chiropractic physician, podiatric physician and surgeon,
naturopathic physician, dentist, physician assistant or nurse practitioner, as follows:
(a) The therapist shall treat
a self-referred patient in accordance with an initial evaluation and treatment plan
prepared by a physical therapist and shall treat a patient who is referred by a
provider of care pursuant to the written or oral referral or authorization received
from the provider. As used in this rule, the term “authorization” includes
certification by a provider of care of the physical therapist’s plan of care
of a Medicare patient.
(b) If the referral or authorization
specifies or identifies specific physical therapy interventions, precautions or
contraindications for therapy, physical therapy shall not be provided beyond those
specifications or limitations without further authorization.
(c) If a patient who is being
treated pursuant to a referral or authorization from a provider of care requests
treatment for a diagnosis or condition that is different and separate from the diagnosis
or condition that is the subject of the referral, the physical therapist may initiate
and provide treatment either in accordance with an initial evaluation and treatment
plan prepared by a physical therapist or pursuant to an additional written or oral
referral or authorization received from a provider listed in this section.
(d) If a referral or authorization
specifies the number of treatments or a duration of treatment, the physical therapist
may treat the patient for that duration and may extend treatment for a reasonable
period of time if necessary for the patient to receive all authorized treatments.
(e) A physical therapist
shall immediately refer a patient to a provider of care if the patient exhibits
symptoms:
(A) That require treatment
or diagnosis by a provider of medical care;
(B) For which physical therapy
is contraindicated;
(C) For which the treatment
is outside that therapist’s knowledge, skill and abilities; or
(D) For which treatment is
outside the scope of practice of physical therapy.
(2) A physical therapist
may provide physical therapy treatment to an animal under a referral from a veterinarian
licensed under ORS Chapter 686. The referral must be in writing and specify the
treatment or therapy to be provided pursuant to 686.040(4). The standard of care
and documentation for physical therapy care to an animal shall be as provided for
veterinarians under ORS Chapter 686.
(3) Notwithstanding the provisions
of this rule, and pursuant to ORS 656.250, a physical therapist shall not provide
compensable services to an injured worker governed by ORS Chapter 656 except as
allowed by a governing managed care organization contract or as authorized by the
worker's attending physician.
Stat. Auth.: ORS 688.160
Stats. Implemented: ORS 688.160,
688.010
Hist.: PTLB 8-2005, f. 12-29-05,
cert. ef. 1-1-06; PTLB 1-2007, f. 3-13-07, cert. ef. 4-1-07; PTLB 2-2008, f. 12-16-08,
cert. ef. 1-2-09; PTLB 2-2013, f. 11-26-13, cert. ef. 1-1-14; PTLB 2-2013, f. 11-26-13,
cert. ef. 1-1-14
848-040-0120
Standards For Record Of Authorization
(1) A written referral received from a provider identified in ORS 688.132(1) shall be included in the patient record. In order to qualify as an authorization, a written referral must include, at a minimum, the name of the patient, the name of the provider, authentication by the provider and the date of the referral.
(2) An oral referral received from a provider identified in ORS 688.132(1) shall be documented in the patient record. Documentation shall include the name of the provider; the name of the person communicating the referral, if not the provider; the date the referral was received; the name of the person to whom the oral referral was communicated; the name of the patient; and a description of the referral, including diagnosis, frequency and duration, if specified.
(3) An oral referral must be followed-up with a written referral from the provider.
Stat. Auth.: ORS 688.160
Stats. Implemented: ORS 688.160, 688.010 & 688.210
Hist.: PTLB 6-2004, f. & cert. ef. 12-29-04; PTLB 8-2005, f. 12-29-05, cert. ef. 1-1-06
848-040-0125
Standards For Initiation Of Physical Therapy
(1) Prior to initiating the
first physical therapy treatment, a physical therapist shall perform an initial
evaluation of each patient and determine a plan of care as provided in OAR 848-040-0135.
(2) For purposes of subsection
(1) of this section, a physical therapist shall perform a separate initial evaluation
under the following circumstances:
(a) The patient is returning
to care after being discharged from therapy; or
(b) The patient is new to an
inpatient or outpatient facility or home health agency.
(3) In the course of performing
an initial evaluation the physical therapist shall examine the patient, obtain a
history, perform relevant system reviews, assess the patient's functional status,
select and administer specific tests and measurements and formulate clinical judgments
regarding the patient. A physical therapist may incorporate by reference medical
history or system review information about the patient prepared by another licensed
health care provider and available in the physical therapy treatment record, IEP,
IFSP or other designated plan of care.
(4) Only a physical therapist
may perform an initial evaluation. A physical therapist shall not delegate the performance
of an initial evaluation to a physical therapist assistant or to an aide.
Stat. Auth.: ORS 688.160
Stats. Implemented: ORS 688.160,
688.010 & 688.210
Hist.: PTLB 6-2004, f. &
cert. ef. 12-29-04; PTLB 1-2007, f. 3-13-07, cert. ef. 4-1-07; PTLB 1-2012, f. 2-9-12,
cert. ef. 3-1-12
848-040-0130
Standards For The Documentation Of An Initial Evaluation
The permanent record of the initial evaluation shall include:
(1) Patient's full name, age and sex;
(2) Identification number, if appropriate;
(3) Referral source, including patient self-referral;
(4) Pertinent medical or physical therapy diagnoses, medications if not otherwise accessible in another part of the patient's medical record, history of presenting problem and current complaints and symptoms, including onset date;
(5) Prior or concurrent services related to the provision of physical therapy services;
(6) Any co-existing condition that affects either the goals or the plan of care;
(7) Precautions, special problems and contraindications;
(8) Subjective information (patient's knowledge of problem);
(9) Patient's goals (with family input or family goals, if appropriate). Goals may be as
provided in an applicable IEP, IFSP, or other designated plan of care; and
(10) Appropriate objective testing results, including but not limited to:
(a) Critical behavior/cognitive status;
(b) Physical status (e.g., pain, neurological, musculoskeletal, cardiovascular, pulmonary);
(c) Functional status (for Activities of Daily Living, work, school, home or sport performance); and
(d) Interpretation of evaluation results.
Stat. Auth.: ORS 688.160
Stats. Implemented: ORS 688.160, 688.010 & 688.210
Hist.: PTLB 6-2004, f. & cert. ef. 12-29-04; PTLB 1-2007, f. 3-13-07, cert. ef. 4-1-07
848-040-0135
Standards For The Plan of Care
(1) Prior to initiation of treatment, a physical therapy plan of care for the patient shall be determined by a physical therapist. As appropriate, a plan of care may include the IFSP, or, in a school setting, a plan of care may include the IEP for a student, or other designated plan of care.
(2) Only a physical therapist may develop a plan of care. A physical therapist shall not delegate the development of the plan of care to a physical therapist assistant or to an aide.
(3) A physical therapist shall identify appropriate treatment tasks to be delegated to a physical therapist assistant or aide.
(4) Only a physical therapist may modify a plan of care. However, a physical therapist assistant may make recommendations to the physical therapist in regards to revision of the plan of care for a patient for whom the physical therapist assistant has been providing treatment.
(5) A physical therapist shall make modifications to the plan of care any time there are significant changes in the patient's condition or status that would affect the physical therapy goals.
Stat. Auth.: ORS 688.160
Stats. Implemented: ORS 688.160, 688.010 & 688.210
Hist.: PTLB 6-2004, f. & cert. ef. 12-29-04; PTLB 1-2007, f. 3-13-07, cert. ef. 4-1-07
848-040-0140
Standards For The Documentation Of The Plan Of Care
(1) The permanent record of the plan of care shall include:
(a) Objectively measurable treatment goals that incorporate the patient's goals;
(b) Proposed treatment to accomplish the goals; and
(c) Proposed frequency and duration of treatment or number of visits.
(2) The permanent record of the plan of care shall be authenticated and dated by the physical therapist who developed the plan.
Stat. Auth.: ORS 688.160
Stats. Implemented: ORS 688.160, 688.010 & 688.210
Hist.: PTLB 6-2004, f. & cert. ef. 12-29-04; PTLB 1-2007, f. 3-13-07, cert. ef. 4-1-07
848-040-0145
Standards For Providing Treatment
(1) A licensee shall not permit an aide to administer a task that is prohibited under OAR 848-020-0060, and shall not permit an aide to administer a non-prohibited procedure or modality to a patient unless a licensee has previously administered that procedure or modality to the patient.
(2) A physical therapist or physical therapist assistant shall perform, or attempt to perform physical therapy interventions only with qualified education and experience in that intervention.
(3) Except as provided in OAR 848-015-0020(6), a physical therapist or physical therapist assistant shall not continue to provide treatment to a patient unless a reassessment has been performed when required by 848-040-0155. However, a physical therapist assistant may provide treatment on the day a reassessment is required, so long as during that treatment day a physical therapist performs the required reassessment.
(4) A physical therapist or physical therapist assistant shall provide treatment in accordance with the provisions of OAR 848-040-0105.
(5) At all times there shall be a physical therapist supervising the treatment provided by a physical therapist assistant as provided in OAR 848-015-0020(2) or an aide as provided in 848-020-0000(5). "Supervising physical therapist" means either the last physical therapist to see the patient, or the physical therapist designated as in-charge of the patient on the day the patient is being treated.
Stat. Auth.: ORS 688.160
Stats. Implemented: ORS 688.160, 688.010 & 688.210
Hist.: PTLB 6-2004, f. & cert. ef. 12-29-04; PTLB 1-2007, f. 3-13-07, cert. ef. 4-1-07; PTLB 2-2008, f. 12-16-08, cert. ef. 1-2-09
848-040-0147
Standards for Treatment by a Student
PT or Student PTA
(1) A physical therapist may allow a
student physical therapist (SPT) or student physical therapist assistant (SPTA),
as defined in OAR 848-040-0100(12), to provide treatment consistent with the individual
student's education, experience and skills.
(2) A physical therapist
assistant may allow an SPTA to provide treatment consistent with the individual
student's education, experience and skills.
(3) At all times, a supervising
physical therapist must provide on-site supervision of an SPT or SPTA who provides
treatment to a patient.
(4) For purposes of this
rule "supervising physical therapist" means the physical therapist who is responsible
for that patient's treatment on the day the SPT or SPTA provides treatment.
(5) For purposes of this
rule "on-site supervision" means that at all times the supervising physical therapist
is in the same building and immediately available to provide in person direction,
assistance, advice or instruction to the student.
(6) A physical therapist
may delegate supervision of an SPTA to a physical therapist assistant and the provision
of subsections (3), (4) and (5) of this rule shall apply to the physical therapist
assistant.
(7) Documentation by a student
physical therapist (SPT) shall be signed by the student and authenticated by a supervising
physical therapist on the same day. Documentation by a student physical therapist
assistant (SPTA) shall be signed by the student and authenticated by a supervising
physical therapist or supervising physical therapist assistant on the same day.
A SPT's documentation must be completed pursuant to OAR 848-040-0110.
Stat. Auth.: ORS 688.160
Stats. Implemented: ORS 688.160,
688.010
Hist.: PTLB 8-2005, f. 12-29-05,
cert. ef. 1-1-06; PTLB 1-2010, f. 2-16-10, cert. ef. 3-1-10; PTLB 2-2013, f. 11-26-13,
cert. ef. 1-1-14
848-040-0150
Standards For The Documentation
of Treatment Provided
(1) The permanent record of treatment
for each patient visit shall include at a minimum:
(a) Subjective status of
patient;
(b) Specific treatments 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;
(C) Adverse reactions to
treatment; and
(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 records 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.
Stat. Auth.: ORS 688.160
Stats. Implemented: ORS 688.160,
688.010 & 688.210
Hist.: PTLB 6-2004, f. &
cert. ef. 12-29-04; PTLB 1-2007, f. 3-13-07, cert. ef. 4-1-07; PTLB 2-2013, f. 11-26-13,
cert. ef. 1-1-14
848-040-0155
Standards For Performing The Required Reassessment
(1) A physical therapist shall perform a reassessment for each patient to update patient status, evaluate progress and to modify or re-direct physical therapy services. In the course of performing the required reassessment, the physical therapist shall personally examine the patient, assess the patient's functional status, select specific tests and measurements, and formulate clinical judgments regarding the patient. The physical therapist may delegate to a physical therapist assistant the gathering of data for the reassessment as provided in OAR 848-015-0030(1)(b).
(2) A physical therapist shall perform a reassessment for each patient:
(a) At least every 30 days, or at every visit if the patient is seen less frequently;
(b) At least every 60 school days if the student is being treated in an educational setting or at every visit if the student is seen less frequently; or
(c) Anytime there are significant changes in the patient's condition or status that would result in a change in the goals or the plan of care.
(3) Only a physical therapist may perform the required reassessment. A physical therapist shall not delegate the performance of a required reassessment to a physical therapist assistant or to an aide.
Stat. Auth.: ORS 688.160
Stats. Implemented: ORS 688.160, 688.010 & 688.210
Hist.: PTLB 6-2004, f. & cert. ef. 12-29-04; PTLB 1-2007, f. 3-13-07, cert. ef. 4-1-07
848-040-0160
Standards For The Documentation Of The Required Reassessment
(1) A physical therapist is required to perform and document the reassessment as required under OAR 848-040-0155.
(2) The permanent record of each reassessment shall include at a minimum:
(a) Subjective status of patient;
(b) Objective data from tests and measurements conducted;
(c) Functional status of patient;
(d) Interpretation of above data;
(e) Any change in the plan of care; and
(f) Any change in physical therapy goals (including patient goals).
(3) After a physical therapist performs a reassessment, a physical therapist assistant may prepare a summary of the patient’s physical therapy status based upon the physical therapist’s performance of the required reassessment.
Stat. Auth.: ORS 688.160
Stats. Implemented: ORS 688.160, 688.010 & 688.210
Hist.: PTLB 6-2004, f. & cert. ef. 12-29-04; PTLB 1-2007, f. 3-13-07, cert. ef. 4-1-07; PTLB 2-2008, f. 12-16-08, cert. ef. 1-2-09
848-040-0165
Standards For Discharging A Patient From Therapy
(1) A physical therapist shall discharge a patient from physical therapy treatment when:
(a) The patient has reached all physical therapy goals and additional goals are not identified;
(b) The patient will not further benefit from physical therapy due to a lack of progress or a plateau in progress;
(c) The patient declines to continue treatment or self-discharges;
(d) Physical therapy is no longer appropriate for the patient or is contraindicated secondary to medical or psychosocial reasons;
(e) The referring provider directs or instructs that the patient be discharged.
(2) Only a physical therapist may make the decision to discharge a patient from therapy. A physical therapist shall not delegate the decision to discharge a patient to a physical therapist assistant or to an aide.
(3) A physical therapist assistant shall not independently make the decision to discharge a patient from therapy. However, a physical therapist assistant may make recommendations regarding discharge to the supervising physical therapist based on the physical therapist assistant's treatment of the patient.
Stat. Auth.: ORS 688.160
Stats. Implemented: ORS 688.160, 688.010 & 688.210
Hist.: PTLB 6-2004, f. & cert. ef. 12-29-04
848-040-0170
Standards For Discharge Records
(1) Within 30 days following the patient's last scheduled visit or last contact, the physical therapist or physical therapist assistant shall document a final summary of the patient's physical therapy status upon discharge.
(2) The discharge summary shall include, but is not limited to:
(a) Date and reason for discharge, or self discharge, if known;
(b) Degree of goal achievement or reasons for goals not being achieved;
(c) Summary of the patient's status at the time of discharge; and
(d) Recommendations for follow-up care, if any.
Stat. Auth.: ORS 688.160
Stats. Implemented: ORS 688.160, 688.010 & 688.210
Hist.: PTLB 6-2004, f. & cert. ef. 12-29-04
848-040-0175
Standards for Screening Services
(1) “Physical therapy screening” means the process of determining whether a person or animal would benefit from a physical therapy evaluation or referral to another health care professional.
(2) A physical therapist or physical therapist assistant may conduct or perform a physical therapy screening of a person who is not currently a physical therapy patient.
(3) A physical therapist or physical therapist assistant shall not delegate the performance of a physical therapy screening to an aide.
(4) A screening is not a physical therapy treatment or intervention and does not require or involve performance of an initial evaluation, preparation of a plan of care, or creation of a patient treatment record.
Stat. Auth.: ORS 688.160
Stats. Implemented: ORS 688.160(6)(g)
Hist.: PTLB 2-2008, f. 12-16-08, cert. ef. 1-2-09
848-040-0180
Standards for Telehealth Services
(1) A Licensee may provide telehealth
services to a patient who is domiciled or physically present in the state of Oregon
at the time the services are provided. An aide may not provide telehealth services.
(2) Telehealth services provided
must conform to the scope and standards of practice and documentation as provided
in Oregon Revised Statutes 688.010 through 688.201 and these Division 40 rules.
Telehealth services must be at least equivalent to the quality of services delivered
in-person.
(3) Prior to the initiation
of telehealth services, a Licensee shall obtain the patient’s consent to receive
the services via telehealth. The consent may be verbal, written, or recorded and
must be documented in the patient’s permanent record.
(4) When providing telehealth
services, a Licensee shall have procedures in place to address remote medical or
clinical emergencies at the patient’s location.
(5) The application and technology
used to provide telehealth services shall meet all standards required by state and
federal laws governing the privacy and security of a patient’s protected health
information.
(6) A Licensee providing
telehealth services to a person who is domiciled in another state and physically
present in that state at the time the telehealth services are being provided, may
be required to be licensed in the state where the services are being rendered.
Stat. Auth.: ORS 688.160(6)(C)
Stats. Implemented: ORS 688.010-688.230
Hist.: PTLB 2-2015, f. 8-27-15,
cert. ef. 9-1-15
The official copy of an Oregon Administrative Rule is
contained in the Administrative Order filed at the Archives Division,
800 Summer St. NE, Salem, Oregon 97310. Any discrepancies with the
published version are satisfied in favor of the Administrative Order.
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