Except as provided in subsection (5) of OAR 848-040-0125, the physical therapist who performs an initial evaluation shall document:
- (1) The patient's identifying information;
- (2) The patient's reason for seeking physical therapy services;
- (3) The patients' relevant medical diagnoses or conditions;
- (4) The patient's signs and symptoms;
- (5) Objective data from tests or measurements;
- (6) The physical therapist’s interpretation of the results of the examination;
- (7) Clinical rationale for therapeutic intervention;
- (8) The plan of care as described in OAR 848-040-0140, and;
- (9) The patient's prognosis.
Statutory/Other Authority
ORS 688.160
Statutes/Other Implemented
ORS 688.160, 688.010 & 688.210
History
OBPT 1-2025, amend filed 01/23/2025, effective 03/01/2025
PTLB 3-2017, amend filed 11/28/2017, effective 01/01/2018
PTLB 1-2007, f. 3-13-07, cert. ef. 4-1-07
PTLB 6-2004, f. & cert. ef. 12-29-04