On a discharge summary, may the Physical Therapist Assistant who has been treating the patient participate in writing the report or does the Physical Therapist need to do this themselves?
Answer
Yes, the first four elements can be performed by the Physical Therapist Assistant. This includes demographics, testing, standard tests and measurements, standardized tests, and all of those types of things. What happens after those first four bullets is that we get into the assessment. That is where the clinician must then take over the progress report. And, on that discharge summary you would have "assisted by" listed as well.
Addendum 9/20/23. Scope of practice is determined at the state level according to state licensure laws. Refer to the most current state laws or your state licensing Board for information and questions about scope of practice in your state.
Mary R. Daulong, PT, CHC, CHP
Mary Daulong, PT, CHC, CHP,is a physical therapist and is also certified in Healthcare Compliance by the Health Care Compliance Certification Board and the HIPAA Academy. Her consulting company, Business & Clinical Management Services, Inc., was established in 1985 and has been, for the past dozen years, 100% dedicated to working with rehab professionals in the areas of federal and state compliance, provider enrollment, practice and business office audits/surveys, payment policy: billing, coding, documentation, and compliance policy and procedure manual production.
Mary is the former chair of the TPTA’s Payment Policy Committee, is a member of the Private Practice Payment Policy Committee, and is the representative for PT & OT for Jurisdiction JH. She is also on Novitas Solutions’ Provider Outreach Education Advisory Board and has recently served on Novitas Solutions’ JH Transition Consulting Team.
Mary has been a featured speaker at National, State, and Section Annual Conferences and is a contributing author to “Compliance Corner” in the Private Practice Section’s Impact Magazine.
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