Skilled or Unskilled?
"Patient performed 3 sets of 10 on the Leg Press."
Unskilled—Observation only
True or False: If a patient’s status hasn't changed, it is acceptable to copy and paste the previous note exactly.
False—Notes must reflect the specific session assessment
Which Principle of the PT Code of Ethics focuses on "Truth-telling" and accuracy in reporting?
Principle 6. Physical therapists and physical therapist assistants shall provide information about their services that is truthful and accurate and shall not make misleading representations in any forms of communication, including billing
In New York State, how many years must you keep a patient's physical therapy record?
6 years
You are working on "Shoulder Range of Motion." Link this to a simple activity of daily living (ADL)
"...to allow the patient to reach into a high cabinet" or "...to brush their own hair."
"Patient performed therapeutic exercises for 15 minutes with standby assistance for safety."
Unskilled—Standby assistance for safety without specific cueing is often considered a "supervisory" role that doesn't require a PT's skill
If you use a "Smart Phrase" or template, what must you do to ensure it isn't considered "cloning"?
Individualize it by adding specific patient responses or modifications made during that session
Principle 3 states PTs shall be accountable for "Sound Professional Judgment." How is this judgment evidenced in a note?
Through the Narrative/Assessment section where you explain the "Why" behind your choices
In NYS, can a Physical Therapist legally accept a verbal referral from a physician?
Yes, but it must be followed by a written prescription/referral within a specific timeframe, usually 30 days)
You are strengthening the Quadriceps. Why does the patient need this for their home environment?
"...to allow for safe stair climbing" or "...to get up from a low toilet seat independently."
"Provided verbal cues for mid-foot strike and analyzed gait for pelvic drop."
Skilled—Shows Analysis & Instruction
What is the specific legal term for copying forward notes without updating them?
Cloned Documentation
Which ethical principle is described: "Physical therapists and physical therapist assistants shall enhance their expertise and competency through career-long acquisition and refinement of knowledge, skills, abilities, and professional behaviors"
Principle 8- Professional expertise.
According to the NYS Practice Act, which document can a PTA not write or sign?
The Initial Evaluation or the Plan of Care
Why should you avoid the phrase "Patient walked 50 feet and tolerated it well"?
Because it doesn't say if they were steady, if they needed help, or why walking 50 feet matters for their goals.
"Instructed patient in diaphragmatic breathing to decrease accessory muscle use and lower heart rate during functional ambulation."
Skilled—Shows Education, Physiological Rationale, and Functional Integration.
True or False: If a patient has the same objective measurements (e.g., ROM) for two sessions in a row, the note is automatically considered a "clone."
False—Plateaus happen, but the Plan and Assessment should explain why the intervention is still skilled or how it is being adjusted
If you witness a colleague consistently "upcoding" or billing for services not provided, what is your ethical obligation?
You must report unethical or fraudulent business practices to the appropriate authority
If you move to a new apartment in Rochester, NY how long do you have to notify the Office of the Professions of your change of address to remain compliant?
30 days—Failure to do so can be considered a registration violation
Your note says, "Patient practiced standing on one leg." Add a functional reason for this exercise.
"...to improve safety when stepping into a bathtub" or "...to maintain balance while putting on pants."
"Modified resistance from 10lbs to 5lbs due to observed compensatory recruitment of the upper trapezius and a 20% drop in O2 saturation."
Highly Skilled—Shows Clinical Decision Making & Physiological Monitoring
An auditor sees 10 days of identical notes. What is the most likely financial consequence for the clinic?
Full recoupment/refund of all 10 days of payment
Under the unified 2026 standards, who is ultimately responsible for the accuracy of a note generated with the help of AI or "Smart Phrases"?
The signing Physical Therapist
What is the legal designation for a PT who fails to maintain an accurate record of treatment?
Professional Misconduct
You are doing 15 minutes of aerobic conditioning. How do you link this to a patient's "community" goals?
"...to increase exercise tolerance required to walk from the parking lot into the grocery store."