1. (a) A physical therapist assistant may assist in the practice of physical therapy only to the extent allowed by the supervising physical therapist.
2. (b) A physical therapist assistant may make modifications of treatment programs that are consistent with the established patient care plan.
3. (c) A physical therapist assistant may engage in off-site patient related activities that are appropriate for the physical therapist assistant's qualifications and the status of the patient.
4. (d) A physical therapist assistant may document care provided without the co-signature of the supervising physical therapist.
5. (e) A physical therapist assistant who is supervising a physical therapy aide or student must be present in the same facility when patient care is provided.

6. (f) The physical therapist assistant must document every intervention/treatment, which must include the following elements:

   1. (1) Authentication (signature and designation) by the physical therapist assistant who performed the service;
   2. (2) Date of the intervention/treatment;
   3. (3) Length of time of total treatment session;
   4. (4) Patient status report;
   5. (5) Changes in clinical status;
   6. (6) Identification of specific elements of each intervention/modality provided. Frequency, intensity, or other details may be included in the plan of care and if so, do not need to be repeated in the daily note;
   7. (7) Equipment provided to the patient or client; and
   8. (8) Response to treatment based on subjective and objective findings, including any adverse reactions to an intervention.

History Note: Authority G.S. 90-270.90; 90-270.92; 90-270.102;
Eff. December 30, 1985;
Amended Eff. December 1, 2006; August 1, 2002;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 1, 2018.