4755-27-07 Documentation.

(A) All physical therapists shall use the credential "PT" following their signature to indicate licensure as a physical therapist.

(B) All physical therapist assistants shall use the credential "PTA" following their signature to indicate licensure as a physical therapist assistant.

(C) All student physical therapists shall use one of the following to indicate student status:

(1) Student physical therapist;

(2) Student PT; or

(3) SPT.

(D) All student physical therapist assistants shall use one of the following to indicate student status:

(1) Student physical therapist assistant;

(2) Student PTA; or

(3) SPTA.

(E) All documentation by student physical therapists and student physical therapist assistants shall be cosigned by the supervising physical therapist.

(F) Appropriate documentation is integral to all facets of physical therapy care. Reports written by the physical therapist assistant for inclusion in the patient's record shall be cosigned by the supervising physical therapist. The cosignature shall indicate that the supervising physical therapist reviewed the written note and agrees with the patient information in the written note. A handwritten signature or electronic signature is acceptable whenever a physical therapist or physical therapist assistant signs his or her name.

(1) Electronic signature means any of the following attached to or associated with an electronic record by an individual to authenticate the record:

(a) A code consisting of a combination of letters, numbers, characters, or symbols that is adapted or executed by an individual as that individual's electronic signature.

(b) A computer generated signature code created for an individual.

(c) An electronic image of an individual's handwritten signature created by using a digital writing apparatus.

(2) If an electronic documentation system is not capable of dual signatures, a physical therapist may enter a separate note within the same documentation system. This note shall:

(a) Reference the date(s) of the note(s) being reviewed with documentation referencing the review; and

(b) Document agreement with the notes entered by the physical therapist assistant and/or changes needed in the treatment plan.

(3) The physical therapist or physical therapist assistant must assure that the electronic signature can be tracked to a unique log in code used only by that individual.

R.C. 119.032 review dates: 02/04/2014 and 02/04/2019
Promulgated Under: 119.03
Statutory Authority: 4755.411
Rule Amplifies: 4755.411
Prior Effective Dates: 5/1/09