Documentation, Recordkeeping, and Reporting Obligations
What this domain tests
The exam tests what must be in the patient record, how records are corrected and retained, and which events a PT must report.
Core rules
- The record should contain the examination and evaluation, PT diagnosis, plan of care, progress notes, delegated interventions, supervision documentation, informed consent, and discharge summary. Entries must be timely, authenticated, and legible.
- Corrections are made with a single line through the error, the correction, the initials, and the date. Never obliterate, backdate, or alter an original entry.
- Retention must meet board rules, state law, and payer requirements; records for minors are generally kept longer. Confirm the current minimum retention period with the board.
- Mandatory reporting may include suspected child abuse or neglect, elder abuse, and other reportable conditions under Louisiana law. PTs should also report suspected fraud and adverse events through the appropriate channel.
Worked example
A PT realizes a progress note omitted a patient fall. She adds a new entry dated today, clearly labeled “late entry,” describing the fall and the response, without changing the original note. Reasoning: the record must be accurate and tamper-evident; a late entry preserves the truth of the original while adding missing information.
Traps that cost marks
- Backdating an entry to match the date of service.
- Deleting or writing over an error instead of correcting it.
- Failing to document a telephone consultation or a patient refusal.
- Assuming HIPAA preempts state reporting laws.
- Destroying records before the retention period ends.