Documentation, Records, and Reporting Obligations
This domain tests what must appear in the record, how the record is protected and corrected, and when a DC clinician must report to an outside agency. Items often hinge on whether the documentation would support the care that was billed.
Required content
- Initial examination/evaluation: history, objective findings and measures, diagnosis, prognosis, plan of care with goals, frequency, duration, and referral information.
- Every visit: date, interventions with parameters, patient response, progress toward goals.
- Reevaluation at defined intervals or on a change in status.
- Discharge summary with outcomes and disposition.
Authentication and corrections
Each entry is signed with name or credential and dated. PTA notes are co-signed by the supervising PT as the rules require. Corrections are made with a single line through the error, initials, and date, leaving the original readable. Never backdate an entry and never remove or destroy a page.
Retention and transfer
Keep records for the retention period the regulations specify after the last visit, longer when the patient is a minor, and arrange custody and patient notice when a practice closes.
Mandatory reporting in DC
- Suspected child abuse or neglect - report to the Child and Family Services Agency; call 911 if there is immediate danger.
- Abuse of a vulnerable adult - Adult Protective Services.
- Reportable communicable diseases - DC Health.
- Impaired colleagues - to the Board where the Act requires it. Good-faith reports carry immunity. Report facts, not conclusions.
Worked example
A nine-year-old presents with a forearm fracture and the caregiver's account changes twice. Document the stated history verbatim, the objective findings, and the fact that a report was made, including the hotline time and the worker's name. Do not interview the child for a forensic account and do not confront the family; investigation is not your role.
Traps
Writing a late entry as though it were contemporaneous; charting "patient improved" without measures; assuming a parent or patient can veto a child-abuse report; failing to document the report itself; discarding the record of a patient who transfers.