5.2 Documentation and Medical Records

Documentation and Medical Records

R4-24-304 defines an adequate physical therapy patient record. A.R.S. §§ 32-2043, 32-2044 and 32-2051 connect that record to PT responsibility, discipline, billing accuracy and confidentiality. Answer from the enumerated elements instead of importing an employer template.

Every entry

Each entry is legible, dated and signed with the author's legal designation. Electronic signatures and security controls must prevent one person from making an entry under another person's identity. The record contains enough information to identify the patient, justify the services, document results, record warnings and precautions, support continuity of care and include relevant medical history.

A person other than a PT or PTA may make an entry only if a PT verifies and co-signs it. This is not permission for an aide to evaluate or exercise clinical judgment; it is an authentication safeguard for a permitted entry. A PTA's compliant entry does not require a routine PT co-signature under Arizona law.

A correction leaves the original information legible and is dated and initialed. Backdating or deleting the original hides the record's history and can create misrepresentation concerns. For every date of service, the documented service and billed service must accurately reflect what was provided.

Initial evaluation

The PT's initial evaluation documents:

1. the reason for referral or care;
2. medical diagnoses or health conditions relevant to physical therapy;
3. current function and relevant prior function;
4. signs and symptoms;
5. objective tests and measures;
6. the PT's interpretation of the examination data;
7. the rationale for the plan;
8. the plan of care, including interventions, goals, frequency and duration; and
9. prognosis.

The rule's list is precise. It does not require an Arizona license number on every entry, although the legal designation and signature are required. A clinic may demand more, but an exam question about the Board rule should use the rule.

Treatment-date entry

For each treatment date, the record identifies the interventions provided, the patient's response, changes in status, progress toward goals, communication relevant to care and the identity of the person providing care. The detail must be sufficient to justify skilled service and continuity. A copied statement that never shows response or progression is unlikely to satisfy the purpose of the rule.

When a PTA works under general supervision, the additional supervision information described in R4-24-303 is recorded, including the supervising PT and consultation information.

Reevaluation

The PT reevaluates when:

• the patient does not progress as reasonably expected;
• the patient progresses enough to warrant a change in the plan of care; or
• the fourth-treatment-visit or 30-day general-supervision requirement is reached.

The reevaluation record includes current status, objective data, interpretation, progress, and any plan changes. Do not turn the general-supervision interval into a universal schedule or wait for it when clinical progress already triggers reevaluation.

Discharge

A discharge record is required regardless of why care ends. Outside the acute-care hospital exception, it records the discharge date and reason, inclusive dates and number of treatment days, current functional status, progress toward goals and the recommended post-discharge plan. In an acute-care hospital, the PT's last treatment note may satisfy the discharge requirement if it contains the required information.

Confidentiality and Board access

Patient information is confidential. A.R.S. § 32-2051 permits disclosure with prior written patient consent and recognizes disclosures required by law, including information the Board requires in an investigation or proceeding and other mandatory reporting. Patient records and identifying information in Board investigative files are protected from general public access. Confidentiality is not a reason to ignore a lawful Board subpoena.

Official anchors

• A.R.S. § 32-2043 — Components of care
• A.R.S. § 32-2051 — Consumer confidentiality
• Arizona Administrative Code, R4-24-304

Record-content drill

An initial evaluation that lists pain and exercises but omits objective tests, interpretation, goals, frequency, duration and prognosis is not rescued by a signature. Authentication and content are separate requirements. A daily record must show what happened and the patient's response; a reevaluation must analyze current data and progress; a discharge record must close the episode with the specified status and recommendations.

Billing follows the same-date record. If a PTA delivers one intervention but a claim reflects a different service or duration, later PT co-signature does not make the billing accurate. The PT is responsible for billing accuracy, while each author remains responsible for truthful entries.

Confidential handling drill

A Board subpoena requests a patient chart during an investigation. The clinic may disclose the requested record through the lawful oversight channel without a separate patient authorization, and the Board applies statutory confidentiality. Sending the same chart to an unrelated marketer would require a different legal basis. “Confidential” governs who may receive information and why; it does not mean no disclosure is ever lawful.