(A) A physical therapist is responsible for the physical therapy record of a patient.

(B) Only a licensed physical therapist or physical therapist assistant, provisional licensed physical therapist or physical therapist assistant, or student physical therapist or physical therapist assistant shall document in a physical therapy record.

Terms Used In South Carolina Code 40-45-280

  • Person: means an individual. See South Carolina Code 40-45-20
  • Physical therapist: means a person who has met all the conditions of this chapter and is licensed in this State to practice physical therapy. See South Carolina Code 40-45-20
  • Physical therapist assistant: means a person who is licensed by the board to assist a physical therapist in the practice of physical therapy and whose activities are supervised and directed by a physical therapist whose license is in good standing. See South Carolina Code 40-45-20
  • physical therapy: as used in this chapter , and nothing in this chapter shall be construed to authorize a physical therapist to prescribe medications or order laboratory or other medical tests. See South Carolina Code 40-45-20

(C) A physical therapy record consists of:

(1) the initial evaluation which is a written report signed and dated by the physical therapist performing the evaluation. An initial evaluation by a provisional licensed physical therapist must be reviewed, cosigned, and dated by the on-site supervising physical therapist;

(2) a plan of care developed by a licensed physical therapist, including:

(a) treatment to be rendered;

(b) frequency and duration of treatment;

(c) measurable goals.

(3) clinical notes that must be signed and dated by the person rendering treatment. All clinical notes written by a physical therapist student or physical therapist assistant student are to be reviewed, cosigned, and dated by the physical therapist or physical therapist assistant who is supervising the appropriate level student. Clinical notes written by a provisional physical therapist or a physical therapist assistant licensee must be reviewed, cosigned, and dated by the on-site supervising physical therapist every eighth treatment day or every sixty calendar days, whichever comes first;

(4) a discharge note which is a statement of the patient’s status at the last treatment session as written, signed, and dated by the physical therapist or physical therapist assistant rendering service. All discharge notes written by a physical therapist student, physical therapist assistant student, and provisional licensed physical therapist or physical therapist assistant are to be reviewed, cosigned, and dated by the supervising physical therapist.