PTA Supervision, Delegation, and the Off-Site PT
A PT at a hospital-based outpatient clinic evaluates Margaret, 72, two weeks after a left middle cerebral artery stroke. She has left hemiparesis, requires a quad cane and standby assistance for gait, and has mild expressive aphasia. The PT establishes a plan of care including gait training, balance activities, and neuromuscular electrical stimulation to the left dorsiflexors. The PT is scheduled to be off-site at a satellite clinic for the next two days. A PTA employed at the clinic is assigned to carry out the plan of care. On the second day, a new patient with a total knee replacement arrives and the PTA is asked to "do the evaluation so we don't lose the referral." The PTA is also asked to sign Margaret's discharge summary because she is nearing her goals. The PTA has 12 years of experience.
1. Which of the assigned activities may the PTA perform for Margaret, and what supervision must the PT provide?
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The PTA may implement the delegated interventions in Margaret's established plan of care: gait training with the quad cane, balance activities, and NMES to the dorsiflexors if the PTA has documented competence and the modality is permitted by clinic policy and Board rules. The PTA may collect data, document progress, and report changes to the supervising PT. The PTA may not perform the initial evaluation, interpret findings to establish a diagnosis, modify the plan of care, or make discharge decisions. Supervision must meet New Mexico Board requirements. Because the PT will be off-site, the PT must confirm that the applicable supervision level permits off-site supervision for this patient and these interventions; if the rule requires on-site supervision for a modality or for a patient with this level of acuity, the PT must arrange coverage or reschedule. The PT remains responsible for the plan of care and must be available to consult. The PT should also ensure the PTA has clear written instructions and a way to reach the PT.
2. Can the PTA perform the initial evaluation for the new total knee patient? Why or why not?
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No. An initial evaluation is a PT-only act under the Physical Therapy Act and Board rules. The PTA may assist by gathering history, taking measurements, or preparing the patient, but the PTA may not evaluate a new patient, establish a diagnosis, determine a plan of care, or decide whether PT is indicated. The request to "do the evaluation so we don't lose the referral" is a business pressure that does not change the legal boundary. If no PT is available, the clinic should reschedule the patient, arrange for another PT to evaluate, or explain the delay. The PTA should decline and document the request and the reason. The supervising PT should be notified, because assigning an initial evaluation to a PTA is a delegation error that could expose both the PTA and the PT to discipline. The clinic's referral relationship does not override licensure law.
3. Can the PTA sign the discharge summary? What should happen instead?
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No. Discharge is a PT responsibility because it requires a re-evaluation of the patient's status against the goals, a judgment about whether skilled services are still needed, and a plan for follow-up. The PTA may provide a final progress note, summarize the interventions delivered, and report Margaret's current function, but the PT must perform the discharge assessment and sign the discharge summary. If the PT is off-site, the PT can review the PTA's data and complete the discharge documentation only if the PT has sufficient information and complies with telerehabilitation or supervision rules; otherwise, the discharge should wait until the PT can see Margaret. The PTA should not sign the summary as if the PTA were the discharging therapist. The PT should also ensure Margaret and her family receive discharge instructions and that any equipment needs are addressed. Signing outside scope is misrepresentation even if the PTA is experienced.