Policy:

The process of patient screening and initial evaluation begins with the initial point of contact whether it be via a medical record review or personal interview with prospective patients or their caregivers. Performance of an initial screen or an evaluation is the role and responsibility of the Physical or Occupational Therapist and it is NOT the role or responsibility of the Physical Therapist Assistant or Occupational Therapy Assistant.

Patients receiving rehabilitation services must receive regular re-evaluations. Performance of a re-evaluation is the role and responsibility of the Physical or Occupational Therapist and it is NOT the role or responsibility of the Physical Therapist Assistant or Occupational Therapy Assistant. During re-evaluations the Physical or Occupational Therapist should consider assessment data from all sources including chart histories and verbal comments of the Physical Therapist Assistant or Occupational Therapy Assistant. In the re-evaluation, the Occupational Therapy Assistant may contribute to the collection of additional evaluative data, as deemed appropriate by the Occupational Therapist. The Physical or Occupational Therapist maintains responsibility for documenting the re-evaluation.

Rationale:

The Board endorses collaborative practice. It is the belief of the Board that the interests of patients are well served by considering input from all those involved in the treatment of a patient. In particular, the Board appreciates a need for efficacious relationships between Physical Therapists and Physical Therapist Assistants and between Occupational Therapists and Occupational Therapy Assistants.

The Commonwealth's statutes and regulations and professional standards of practice allow for the delegation of selective forms of treatment to PTAs and COTAs. The responsibility for treatment initiation, modification, and termination remains with the Physical Therapist or Occupational Therapist. The Physical or Occupational Therapist retains ultimate responsibility for provision of services. Because licensees frequently ask the Board questions regarding professional roles, the Board seeks to clarify existing Massachusetts statutes and regulations with the following definitions and statement.

Definitions:

Screening is defined as a preliminary process of gathering and integrating information to determine the need for further examination or intervention. Screening is based on a problem-focused, systematic collection and analysis of data to identify individuals in need of physical or occupational therapy intervention or other health care services. A screen is a process involving patient observation, chart review, and discussion with nursing staff. The purpose of a screen is to determine if an initial evaluation by a Physical or Occupational Therapist is indicated.

Assessment is defined as the measurement or quantification of a variable (e.g., tub transfers; dressing as part of an ADL assessment) or the placement of a value on something.

Evaluation is defined as a formal interpretation of patient status that will determine whether or not physical or occupational therapy is indicated; establish diagnoses; prognosis; and identify the interventions to achieve goals.

Re-evaluation determines whether treatment should continue; reestablishes or modifies goals, and changes treatment plans accordingly.

The Board considers the following clinical protocols to be evaluation procedures:

  • Screens
  • An initial evaluation, re-evaluation, or discharge evaluation
    (including Page 3 referrals)
  • Care plans
    (including monthly plan of care)

The process of patient screening and initial evaluation begins with the initial point of contact whether it be via a medical record review or personal interview with prospective patients or their caregivers. Performance of an initial screen or an evaluation is the role and responsibility of the Physical or Occupational Therapist and it is NOT the role or responsibility of the Physical Therapist Assistant or Occupational Therapy Assistant.

Patients receiving rehabilitation services must receive regular re-evaluations. Performance of a re-evaluation is the role and responsibility of the Physical or Occupational Therapist and it is NOT the role or responsibility of the Physical Therapist Assistant or Occupational Therapy Assistant. During re-evaluations the Physical or Occupational Therapist should consider assessment data from all sources including chart histories and verbal comments of the Physical Therapist Assistant or Occupational Therapy Assistant. In the re-evaluation, the Occupational Therapy Assistant may contribute to the collection of additional evaluative data, as deemed appropriate by the Occupational Therapist. The Physical or Occupational Therapist maintains responsibility for documenting the re-evaluation.

Revised February 28, 2013