Nev. Admin. Code § 640.Sec. 23 - NEW
Documentation of the care provided to each patient must be complete and must include, without limitation:
1. For an initial evaluation:
(a) History, systems review and tests and
measures.
(b) Synthesis of data to
include identification of the level of impairment, activity limitations and
participation restrictions.
(c)
Physical therapy diagnosis and prognosis.
(d) Predicted level of improvement.
(e) Goals, treatment interventions, proposed
frequency, duration and discharge plans.
2. For daily notes:
(a) Patient reports.
(b) Treatment interventions, responses to
treatment interventions and factors that modify frequency or intensity of
treatment interventions.
(c)
Progression within the plan of care and the plan for the next visit.
3. For reevaluation or
reassessment, data from repeated or new examination elements, sufficient to
evaluate progress and to modify or redirect treatment interventions.
4. For discharge:
(a) Summary of progression towards
goals.
(b) Discharge instructions,
as the availability of the patient allows.
Notes
NRS 640.050
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No prior version found.