Checklist: Treatment Notes

Want to know if you got it all done? Here's a quick checklist!

Key Points

Expect to spend an average of 60-75 minutes (4-5 billable units) with a patient. Be sure to check insurance coverage as there are some plans that limit visit length to one hour (United HealthCare).

Make therapy fun - LifeCare promotes a mobile clinic model so build a toolbox of fun supplies for therapy. Ideas include weights, balance pads, cones, tape for an obstacle course, pool noodles, and other fun dollar-store finds for GM/FM tasks. Ask us if you need ideas!

Bring To Every Visit:

• PPE (gloves/mask)

• Gait belt

• BP Cuff

Schedule appointments with patients - we are not drop in!

You can only do "8" visits of therapy at a maximum between supervisory visits; you can track visits in the EMRs. If not on the schedule in the EMR, please notify the supervisory a week before a supervisory visit is needed.

You are paid based on the date that the note is signed (not the date of the visit). Documentation is expected to be done by midnight on Sunday every week .

Steps

Schedule appointment with patient and add to your EMR calendar so team members are aware of the appointment;

Appointment Type is Standard Visit (in or out of area)

Arrive The Visit

Load Chart Template

• Arrive the Visit and go to the "Paper" Icon in upper right to access the Templates and load the correct template for your visit (Daily Encounter Note)

Complete the Note

• Update treatment goals.

• Add procedures and summary of intervention.

• Sign the note

What To Document:

Documentation is required for each treatment day and every therapy service. Regulatory Guidelines require that subsequent visit documentation include:

● Patient self-report;

● Reaction/response to intervention;

● Any communication/consultation with other providers;

● Any significant unusual or unexpected changes in clinical status;

● Justification of billing (Documentation of Procedures performed)

● Notation of non-skilled treatment or activities (such as rest periods) are to be voluntarily reported to explain the total treatment time.

Therapists are encouraged to update “Current” status of goals whenever appropriate to provide documentation of interim gains made between Supervisory Visits/Progress Reports. Every treatment note should be different - carry over of documentation when there is no change needs to be explained (i.e., determined that the patient could not advance therapy exercise program and continued ther-ex 3 x 10 of ___)

Learn More

See the Video on Treatment Visits here

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