OAR 848-040-0130: Standards For The Documentation Of An Initial Evaluation

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.