Revisit: Narrative Note

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)

Note Walkthrough

Documentation Checklists

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!