Documentation, Informed Consent, and Patient Records
Domain 4 tests two linked duties: making a record that would let another clinician treat the patient, and obtaining a consent that is real rather than merely a signature.
The patient record
- Every patient needs a record containing examination findings, evaluation, PT diagnosis, plan of care with measurable goals, each intervention with date and response, communications with other providers, and a discharge summary.
- Entries are contemporaneous, dated, authenticated with name and credentials, and legible. Late entries are labeled as late. Errors are corrected by dated addendum; original text is never obliterated.
- The record belongs to the provider; the patient has a right to copies. Release to others requires valid authorization or a legal requirement. Retention runs from the last date of service for the period the Board's regulation specifies, with a longer rule when the patient is a minor.
Informed consent
- Elements: the nature of the intervention, expected benefits, material risks, reasonable alternatives (including declining), and the right to withdraw at any time.
- Obtain consent before care begins and again before material changes; document what was discussed, with whom, and when. For a minor, obtain parent or guardian consent and the patient's assent.
- Separate, specific consent applies to research, photography, and student participation.
Worked example
A patient with osteoporosis agrees to manual therapy. Reasoning: consent should name the fracture risk specific to her condition rather than a generic statement; the therapist documents the discussion, her questions, and her agreement before the first mobilization.
Traps
- Believing a signed form proves informed consent without discussion.
- Documenting consent after the intervention to finish the note.
- Assuming implied consent covers elective outpatient care.
- Altering an old entry instead of adding an addendum.