Documentation, Informed Consent, and Recordkeeping
Documentation standards
Patient records must be accurate, timely, legible, and complete. Documentation should reflect the examination findings, the plan of care, interventions, patient response, and progress toward goals. Entries should be dated and authenticated by the treating provider. Corrections must be made in a way that preserves the original entry (e.g., single line, initialed, dated) rather than obliterating it.
Informed consent
Informed consent requires that the patient receive information about the nature of the proposed intervention, its risks and benefits, and reasonable alternatives, and that the patient voluntarily agree. Consent may be written or, depending on the circumstances, documented verbally in the record. Special considerations apply to minors and to patients who lack decision-making capacity, where a legally authorized representative consents.
Recordkeeping and confidentiality
Records are confidential and may be released only as authorized by the patient or as required by law. Retention periods and access rights are governed by Board rules and applicable law. Candidates should understand that patients generally have a right to access their records and that the PT must maintain records that support the care provided.
Question traps
- Believing a verbal consent is invalid - it may be acceptable if documented.
- Assuming records can be altered by rewriting the original entry.
- Forgetting that consent is an ongoing process, not a one-time signature.
- Overlooking that minors and incapacitated adults require representative consent.
Rule of thumb
Document with the who, what, when, why, and response framework, and treat every correction as an addendum, never an erasure.