Eli's Rehab Report
Check What a Tech May Or May Not Document
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Question: We are currently building out our EMR content and the following questions came up about Physical Therapy techs.
1. Can a tech data enter the patient’s history from the paper intake form for the PT to review and sign off on?
2. Can a tech document exercise flow sheets themselves in the EMR? Some of our therapists are under the impression that techs are not allowed to document anything in the PT chart. Is this correct or not?
Answer: This is what our experts have to say:
There is no one answer to this question as it is state practice act-specific and discipline-specific in every state, says Rick Gawenda, PT, President, Gawenda Seminars & Consulting, Inc. The therapist would need to read their respective state practice act to see if they can use support personnel. And if so, what they can do, and whether they can document in the medical record.
“There’s no one answer — the rules vary from state to state; each state licensing board makes the rules,” PTPN Director of Quality Assurance Mitchel Kaye, PT, agrees.
“It depends upon state law. In New York State techs have equivalent responsibilities as that of a medical assistant. So they are allowed to document certain things such as information from an intake form. They cannot document SOAP notes or observations (to remain compliant with privacy laws),” says Ester Horowitz, CMC, CITRMS, certified management counselor and owner/practice marketing advisor with M2Power Inc. in Merrick, N.Y.
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