Documentation, Records Retention, and Confidentiality
Documentation items test whether the record would support the care if the Board, a payer, or a court read it years later. Georgia expects the record to show the evaluation, the plan, the rationale, the progress, and the discharge - and to show that confidentiality was respected when information moved.
What the record must contain
- Initial examination and evaluation with objective findings and functional limitations.
- A plan of care with measurable goals, intervention types, frequency, and duration, signed by the PT.
- Progress notes that link interventions to goals, plus re-evaluation when the plan changes.
- Discharge summary with outcomes and the reason for discharge.
- Authentication: date, signature, and credentials, with late entries added without altering the original text.
Corrections and retention
Errors are corrected with a single line through the entry plus the correction, date, and initials - never by erasing, whiting out, or rewriting. Board rules set a minimum retention period; a safe operating standard is at least five years after the last service, and longer for minors (until the age of majority plus the retention period). HIPAA covered entities must retain required documentation for six years. When a practice closes, patients must be notified and records preserved or transferred.
Confidentiality in practice
Releases must be specific and written, identifying the patient, the information, the recipient, the purpose, and an expiration, and the patient may revoke them. A subpoena alone is not automatically sufficient - verify a court order or a patient authorization. Share only the minimum necessary, and treat fax, email, and portal transmission as disclosures that must be secured.
Worked example
An attorney sends a subpoena for a patient's entire chart. The therapist should not fax the chart that afternoon. Confirm the subpoena is valid and that the patient has been notified, check whether a protective order applies, and release only the records requested. Document what was released, to whom, and when.
Traps
Backdating notes; adding to a note after a records request without labeling the addition; assuming therapy notes are exempt from patient access; discarding records at the end of employment rather than at the end of the retention period.