Question: Documentation for Rehabilitation Assessment

Is documentation solely by a Physical Therapy Assistant or Occupational Therapy Assistant acceptable to determine if a patient was assessed for rehabilitation? Or, must the documentation be from a Physical Therapist or Occupational Therapist, or Speech-Language Therapist?

Answer:

Documentation by a PT or OT assistant is acceptable. Notes written by a certified nursing assistant (CNA) or health care technician (HCT) are not acceptable and excluded.