Follow state laws on documentation. See your state regulatory agency.
Example: Oregon regulations state: “Documentation: Athletic trainers are required to accept responsibility for recording details of the athlete's health status and include details of the injured athlete's medical history, including name, address and legal guardian if a minor, referral source, all assessments, test results, database by date of service provided, treatment plan and estimated length for recovery, record all methods used, results achieved, any changes in the treatment plan, record the date that the treatment plan is concluded and provide a summary, sign and date each entry.”
- Follow payer specific requirements for documentation.
- Familiarize yourself with CMS guidelines on outpatient therapy services and documentation.
- Documentation Coding & Guidelines