Question:

Do you know if an EOB is considered part of a patient's record and if so, does an ERA need to be downloaded and stored either in the patient's record or on a storage device?

  

Response:                                                  

The "patient record" for PT is defined in N.J.A.C. 13:39A-3.1:

 

(c) The patient record shall include, in addition to personal identifying information, consents and disclosures, at least the following information:

  

1. The full name, as it appears on the license, of the licensee who rendered care, identification of licensure status (PT or PTA), and license number. This information shall be legible and shall appear at least once on each page of the patient record;

2. Dates of all examinations, evaluations, physical therapy diagnoses, prognoses including the established plans of care, and interventions;

3. The findings of the examination including test results;

4. The conclusion of the evaluation;

5. The determination of the physical therapy diagnosis and prognosis;

6. Documentation of health care practitioner referrals, if any:

7. A plan of care establishing measurable goals of the intervention with stated time frames, the type of intervention, and the frequency and expected duration of intervention;

8. A contemporaneous note that accurately represents the services rendered during the treatment sessions including, but not limited to, the components of intervention, the patient's response to intervention and current status;

9. Progress notes in accordance with stated goals at a frequency consistent with physical therapy diagnosis, evaluative findings, prognosis and changes in the patient's conditions;

10 .The signature or initials and license number of the licensee who rendered care. If the licensee chooses to sign by means of initials, his or her complete signature and license number shall appear at

least once on every page;

11. Changes in the plan of care which shall be documented contemporaneously;

12. Communication with other health professionals relative to the patient's care;

13. A discharge summary which includes the reason for discharge from and outcome of physical therapy intervention relative to established goals at the time of discharge; and

14. Pertinent legal document(s)

  

As you see above, the regulation includes no definition for "pertinent legal documents", but an Explanation of Benefits (EOB) and Electronic Remittance Advice (ERA) certainly could arguably be described as such. More importantly, such records could certainly be requested in an administrative or legal proceeding, and could thus be considered "required" in the broadest sense. Furthermore, it is important to understand that documentation is always ones best, and sometimes only defense when one is accused of wrongdoing. The absence of such records can therefore be very damaging to that defense.

  

Given the above, it would likely be advisable to maintain such records, either electronically or in hard copy form, along with the patient records for a minimum of seven years. Perhaps most importantly; the determination of what constitutes a patient record, or what constitutes pertinent legal documents, is ultimately made by either administrative agencies and/or the courts.

 

Question:  

Do the massage therapists have a practice act, rules and regulations? This massage therapist advertises laser therapy. I will report her to the BOPTE since infrared light is covered under our practice act and therefore she is practicing physical therapy.

 

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