Documentation, Patient Records, and Reporting Obligations
What the exam tests
Documentation questions test whether the record is complete, timely, and defensible, and whether the licensee knows retention and reporting duties. The record is both a clinical tool and legal evidence.
Record content
- Patient identification, date of service, evaluation findings, diagnosis within PT scope, plan of care, goals, interventions, patient response, and discharge summary.
- Informed consent, referrals, and communication with other providers.
- Entries must be legible, dated, authenticated, and completed promptly. Late entries should be identified as late, not backdated.
Retention and security
Board rules set a minimum retention period; a common standard is at least five years after the last date of service, with a longer period for minors. Electronic records must be secure, access-controlled, and backed up. Release only with authorization or as required by law.
Reporting obligations
Licensees must report suspected abuse, neglect, or exploitation as required by New Mexico law, and must cooperate with Board investigations. Adverse events and practice changes that affect patient safety should be documented and communicated. Do not alter a record after a complaint is filed; that is itself a disciplinary issue.
Worked example
A PT realizes she documented the wrong resistance level. She draws a single line through the error, writes the correct value, dates it, and initials it. She does not erase, use correction fluid, or create a new note dated earlier. The correction preserves the audit trail.
Traps that cost marks
Do not use vague phrases such as 'patient tolerated well' without objective or functional detail. Do not omit the discharge summary. Do not release records to an employer or attorney without proper authorization or legal process. Do not destroy records before the retention period ends.