Frequently Asked Questions
How do I document informed consent?
The Arizona State Board of PT Rules (A.A.C. R4-24-301.C.) require a physical therapist to obtain a patient’s informed consent before treatment, which “shall be in writing or documented in the patient chart…”. This could be fulfilled by the use of a written statement of informed consent signed by the patient, a checklist that includes informed consent for treatment signed by the patient, or a notation in the patient record that documents the patient’s consent to treatment. The Rules further require that informed consent must include information concerning the nature of treatment, material (decisional) risks of harm or complication, reasonable alternative(s) to the proposed treatment and the goals of treatment. The APTA Board of Directors “Guidelines for Physical Therapy Documentation” recommends that handwritten entries should be made in ink and include original signatures, and electronic entries should be made with appropriate security and confidentiality provisions.
Can a physical therapy aide/technician document in the patient record?
The Arizona PT Statute and Rules are silent about the aide/tech’s role in documentation. The law does specify that documentation for each treatment session needs be signed either manually or electronically by either the PT or the PTA (A.A.C.R4-24-303.D), which means that entries written by an aide/tech must be authenticated by the supervising PT. Only a PT can document the initial evaluation, periodic re-evaluation, a discharge summary, and all therapeutic interventions that require the expertise of a PT (A.A.C. R4-24-303.A). Your signature should include your professional designation. Documentation written by PT or PTA student should be authenticated by the supervising physical therapist.