OAR 848-040-0150. Standards For The Documentation of Treatment Provided

(1) Except as provided in subsection (5) of OAR 848-040-0125, documentation of treatment for each patient visit shall include at a minimum: (a) Subjective status of patient; (b) Specific therapeutic interventions, information, and education provided; (c) Objective data from tests and measurements conducted; (d) Assessment of the patient's response to therapeutic interventions, and, (e) Updates to the plan of care. (2) A supervising physical therapist may document treatment provided by a physical therapist assistant. If the supervising physical therapist records and authenticates treatment provided by the physical therapist assistant, the physical therapist shall document which treatment interventions were provided that day by the physical therapist assistant. When treatment is provided or assisted by an aide, the aide may only document objective information about the treatment intervention 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 treatment interventions were provided that day by the aide.