What documentation is required when a physical therapist refers a patient for additional services?

When a physical therapist refers a patient for additional services, it is essential that the referral is documented in the patient's record. This documentation plays a crucial role in providing continuity of care, ensuring that all healthcare providers involved in the patient's treatment are aware of the referral. Additionally, it maintains a clear and accurate account of the patient's treatment history, which is essential for legal and ethical reasons.

Proper documentation allows for tracking the patient's progress and making any necessary adjustments to their treatment plan. It serves as a communication tool between the physical therapist and the specialist or additional service providers to ensure that the patient's needs are met comprehensively.

In the context of the options, not documenting the referral would compromise patient care and could potentially lead to misunderstandings or errors in treatment. Verbal communication alone may not provide a reliable record and could be subject to miscommunication or overlooked details. Thus, having a formal record in the patient's file solidifies the authorization of the referral, protects patient information, and adheres to the standards of practice required in the field.