Documentation and Patient Records
Documentation and Patient Records
This domain tests what must be in the record, how to correct it, and how long to keep it.
Core rules
- Create a record for every patient. Include the referral if any, history, examination and evaluation, PT diagnosis, plan of care, goals, interventions, patient response, progress, education, and discharge summary.
- Entries must be dated, authenticated, and legible. In an EHR, use your own unique credentials. Never share passwords or sign for another clinician.
- Corrections must be transparent. On paper, draw a single line through errors, initial and date, and add correct information; do not obliterate. In EHRs, use addenda rather than silent edits.
- Late entries are allowed but must be labeled as late and dated when written, not backdated to the treatment date.
- Maintain records for the period required by Missouri law and payer contracts. A common retention period is at least seven years after the last service, and longer for minors. Destroy records securely.
- Release records only with valid authorization or a legal exception.
Worked example
A PT realizes three days later that the discharge note omitted the patient’s final gait distance. The PT adds an addendum dated today: “Addendum: 1/15 - final gait distance 150 ft.” Reasoning: this is transparent and preserves the original. Backdating the note to the discharge date would be falsification. If the omitted fact changes the plan, document the clinical response too.
Traps
Do not chart “patient tolerated well” without objective or functional detail. Do not let a student or aide sign your entry. Do not alter a record after receiving a records request or complaint.