For documentation of ongoing therapy services that are not at the time of initial evaluation, recertification or the 5 day window, clinicians should use the note type Re-visit>Narrative Note. If this is a clinician's first visit with a patient but it is not an evaluation, such as in the case of a transition, the Re-visit note type should be selected. The Initial Visit category is only used at initial evaluation.
Remember, the Narrative section of your note should always include the following:
Where did the visit occur (In Home or Telehealth)
Who was present
Level of alertness/participation
PPE worn if applicable
Medication updates, including if there are no changes
Specific caregiver education
specific therapy recommendation to the session (not a "blanket statement")
crediting yourself as the one providing the education
Example: "OT provided CG education regarding regulation strategies of deep pressure and brushing protocol this visit."
Example: ST provided education to MOC regarding expansion and recasting of patient's 2-word utterances to provide models of 3-4 word utterances during structured play or reading.
Collaboration with supervisor, if an assistant
Plan for ongoing services "Continue with POC"
Statement regarding reason if no signature was captured (telehealth)
The Documentation Checklist is a great resource to make sure you are completing all necessary components in your documentation. This document covers daily notes, transition visits, missed visits and more!