Direct access, patient examination, and referral requirements
What this domain tests
This domain asks whether a patient needs a physician referral before physical therapy, what the PT must do at the first visit, and when referral or collaboration is required. The key is separating practice-act rules from insurance or employer rules.
Core rules and concepts
- New Hampshire permits direct access to physical therapy. A patient may seek examination and treatment without a physician referral, subject to the practice act and Board rules.
- The PT must perform an initial examination that includes history, systems review, and appropriate tests and measures; identify precautions and contraindications; establish a diagnosis of movement dysfunction; and develop a plan of care.
- The PT must refer the patient to an appropriate healthcare provider when findings suggest a condition requiring medical diagnosis or treatment, when red flags appear, when the patient does not progress, or when the patient needs services outside the PT's scope.
- The PT should document referral status and any communication with other providers. Payers, employers, and workers' compensation programs may require a referral even when the practice act does not.
Worked example
A patient walks in with calf pain after a long flight. Direct access allows the PT to examine the patient, but the history and findings suggest possible deep vein thrombosis. The PT does not begin aggressive massage or exercise. The PT refers immediately for medical evaluation and documents the red flags, the referral, and the instructions given. Direct access does not authorize treating a condition outside physical therapy scope.
Traps that cost marks
Do not say direct access means no physician involvement ever. Do not confuse a payer's referral requirement with a licensure requirement. Do not treat a patient with unexplained red flags because the patient requested therapy.
Exam focus
Ask three questions: does the practice act permit treatment without referral, does the examination reveal a condition needing referral, and does a payer or setting impose an additional requirement?