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Physician orders must be present for all residents receiving therapy. There must be an order for the initial evaluation. Physicians must document that they have reviewed the plan of care developed by the therapist and order the outlined service. Services must be reordered at each evaluation and no less often than monthly.

The same documentation protocol should be used for both Part A and Part B therapy. If restorative therapy is being provided, the notes should clearly document the reason why therapy is being provided regardless of payment source. Part A and Part B therapy notes should clearly indicate what the resident's prior level of function was. In all situations, therapy and nursing notes must be consistent.