334.602. Patient record documentation requirements. - Missouri Statutes

Patient record documentation requirements.

334.602. 1. Physical therapists and physical therapist assistantsshall provide documentation in order that an adequate and complete patientrecord can be maintained. All patient records shall be legible andavailable for review and shall include at a minimum documentation of thefollowing information:

(1) Identification of the patient, including name, birth date,address, and telephone number;

(2) The date or dates the patient was seen;

(3) The current status of the patient, including the reason for thevisit;

(4) Observation of pertinent physical findings;

(5) Assessment and clinical impression of physical therapy diagnosis;

(6) Plan of care and treatment;

(7) Documentation of progress toward goals;

(8) Informed consent;

(9) Discharge summary.

2. Patient records remaining under the care, custody, and control ofthe licensee shall be maintained by the licensee of the board, or thelicensee's designee, for a minimum of seven years from the date of when thelast professional service was provided.

3. Any correction, addition, or change in any patient record shall beclearly marked and identified as such, and the date, time, and name of theperson making the correction, addition, or change shall be included, aswell as the reason for the correction, addition, or change.

4. The board shall not obtain a patient medical record withoutwritten authorization from the patient to obtain the medical record or theissuance of a subpoena for the patient medical record.

(L. 2008 S.B. 788)