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Therapy Assistants and the Discharge Summary

Mary R. Daulong, PT, CHC, CHP

August 23, 2012

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Question

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

Mary R. Daulong, PT, CHC, CHP

Mary Daulong, PT, CHC, CHP has a very diverse practice background which includes private practice ownership, corporate managed services and hospital based practice exceeding four decades. Her consulting company was established in 1985 and has been, for the past ten years, 100% dedicated to working with healthcare professionals in the areas of federal and state compliance, practice and business office operations, payment and coverage policy including billing, coding and documentation. Her company also provides rehabilitation specific compliance policy and procedure manual production and provider enrollment services.

Mary has been certified in Health Care Compliance since 2002 and is a member of the Healthcare Compliance Association she is also certified as a HIPAA Professional by the HIPAA Academy. Mary has been an active member of the APTA and just recently served as its Risk Management Committee chair. She is a member of the APTA’s State Reimbursement Chair Forum and has held the position of Chair of the Texas Physical Therapy Association’s Payer Relations and Payment Policy Committee for nearly six years.  She served for five years on the Texas Board of Physical Therapy Examiners as well as was a member of its Executive Council for PT and OT and Investigations.

 Mary has presented well over one hundred (100) courses related to compliance both on a federal and state level often being the featured speaker at National, Chapter and Section Annual Conferences.


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