Declaratory Statements - Medical Records

1. Out-Patient P.T. Records 1 - How long must out-patient P.T. records be kept? (And does it matter if they were private pay or Medicare patients?)

   There are two answers to this question, each based on the type of facility in which the P.T. practices. As set forth in the Hospital Records and Retention Act, LSA R.S. 40:2144F(1)"Hospital Records shall be retained by hospitals in their original, microfilmed, or similarly reproduced form for a minimum period of ten years from the date a patient is discharged." In the second situation, LSA R.S. 40:1299.96A of the Health Care Information Act states "medical records of a patient maintained in a healthcare providers office are the property and business records of the health care provider." This includes the physical therapists' offices and provides as follows: "Medical Records shall be retained for a minimum period of 6 years from the date a patient is last treated..." In both cases, graphic matter images, e-ray film and like matter that were necessary to produce a diagnostic or therapeutic report shall be retained, preserved, and properly stored for a minimum of 3 years. With regards to civil issues, it is suggested you contact a private attorney with regards to your rights and obligations concerning civil issues. For example, any rights that a minor has is generally suspended until one (1) year after he reaches the age of majority. The age of majority with regards to civil rights in Louisiana is eighteen (I8) years of age. In other words, if a minor child has any claim against you in a civil matter, such claim may be brought by such minor until he reaches nineteen (19) years of age. Again, the Board is not providing you with any advice regarding the age minority issue, but rather suggesting that you might want to contact a private attorney for appropriate advice.

2. Out-Patient P.T. Records 2 - Is the date of destruction from the date of initial visit or the date of discharge?

   The time periods required in the Records Retention Acts begin to run with the last date the patient is seen by the therapist which in all probability will be the date of discharge.

3. Written Documentation of 6th Visit - I am a PTA in home health and have a question regarding the weekly face to face case conferences. Is a written record required or is it a "not written-not done situation?" Are there any PT Board requirements that need to be included in the written documentation or is a generic statement sufficient?

   Rule 321A.2.d promulgated by the Board requires that with regards to the requirement of periodic supervision the physical therapy services rendered by a licensed physical therapist in home health settings, the supervising physical therapist shall conduct, once weekly, a face to face patient care conference with each physical therapist assistant to review progress and modification of treatment programs for all patients. The Board recommends that the face to face conference be documented with both the physical therapist and physical therapist assistant signing the record. Such a procedure of documentation will protect both the physical therapist and physical therapist assistant by confirming that a weekly face to face conference has occurred. With regards to the content of such documentation, the Board is of the opinion that a generic statement is sufficient unless there is a change in the treatment plan. If the treatment plan is changed, then you are referred to Rule 323 regarding documentation standards which would have to be complied with.