PTA Performing an Initial Examination at a Satellite Clinic
A physical therapist is the clinical director of two Louisiana clinics and spends most of the week at the main site. A physical therapist assistant at the satellite clinic sees a new patient with a lateral ankle sprain, performs an initial examination, identifies limited dorsiflexion and weakness, and establishes a plan of care consisting of manual therapy, strengthening, and electrical stimulation. The assistant treats the patient for 12 days. The supervising therapist reviews the chart at day 12 and signs the assistant's notes, then changes the plan to add balance training. The patient has diabetes and reports numbness in the foot. The assistant had also switched from ultrasound to electrical stimulation on day 6 without contacting the therapist because the assistant thought the change was within the plan. The clinic's policy says the therapist must be available by phone but need not be on site.
1. Which parts of this course of care could the PTA perform, and which parts were outside the PTA's scope under Louisiana law?
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Louisiana law and Board rules reserve the initial examination, evaluation, diagnosis, prognosis, and establishment of the plan of care to the physical therapist. A PTA may provide treatment and selected interventions within an established plan of care and may modify treatment parameters only as authorized by the supervising therapist and permitted by Board rule. Here, the PTA performed the initial examination and set the plan of care. That is outside the PTA scope, even if the PTA is experienced. The PTA also changed from ultrasound to electrical stimulation without contacting the therapist. That change may be a treatment modification rather than a new plan, but the record must show that the therapist authorized it or that the plan permitted it. The therapist's later signature does not retroactively make the initial examination a PT service. The therapist should have performed the initial examination, established the plan, and documented supervision.
2. Was the supervision arrangement adequate? Consider the satellite setting, the telephone availability, and the 12-day retrospective review.
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Not clearly. Louisiana requires the supervising physical therapist to provide a level of supervision consistent with the patient's condition and the PTA's competence, and the therapist remains responsible for the plan of care. Telephone availability alone may be insufficient for a new patient with diabetes and sensory loss, especially when the PTA is performing an initial examination and changing interventions. The Board expects the PT to be available for consultation and to provide on-site supervision as needed; the exact frequency depends on the rule and the patient's acuity. A 12-day retrospective chart review is not the same as prospective supervision. The therapist should have been involved before treatment began, should have seen the patient or at least reviewed the examination findings promptly, and should have documented the supervision method. The clinic policy cannot override the Practice Act or Board rules. The therapist should revise the supervision schedule and ensure the satellite PTA has direct access to the PT for changes in condition.
3. What should the documentation show for supervision and for the PTA's notes?
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The documentation should identify the supervising PT, the dates and methods of supervision, the patient-related issues discussed, and any changes authorized. PTA notes should be timely, accurate, and co-signed or reviewed by the PT as required by Board rule. The record should show that the PT established the plan of care and that the PTA's interventions were within it. If the PTA changed a modality, the record should reflect the rationale, the PT's authorization, and the patient's response. The therapist's day-12 signature should include a substantive review, not just a signature. Because the patient has diabetes and numbness, the record should also document skin and sensation checks and any communication with the PT about those findings. Missing these elements makes it difficult to show that supervision was adequate and that the PTA stayed within scope.