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Introduction

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As you know from prior chapters, every time a therapist is scheduled to see a patient, there should be documentation that corresponds with that scheduled session, whether it is attended or missed for any reason. Previous chapters have focused on the components present in three of the therapy notes: the initial evaluation, the re-evaluation, and the discharge note. Often, the most frequently used note written is the daily visit note.1 This chapter addresses the components of the daily visit note that should be used every time you see a patient.

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The daily visit note is referred to and known by multiple names, including visit note, encounter note, daily note, or daily visit note. No matter how a particular facility refers to this note, the components it should include are universal. The purpose of the daily visit note is to document the specific implementation of the patient's plan of care, the response to care, and the patient's function and progress in therapy in between formal evaluation, re-evaluations, and discharge.1

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Components of the Daily Visit Note

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In addition to the basic components that are present in every health record entry, as noted in Chapter 6, the following components should appear in every daily visit note1:

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  • Subjective report from the patient:

    • New complaints unrelated to underlying referral diagnosis and/or ongoing complaints related to underlying referral diagnosis.

    • Compliance with prior instruction or home exercise program and any obstacles making it difficult to comply with prescribed instructions.

    • Report of pain by the patient, including mitigating factors for change in pain.

  • A list of all objective interventions completed with the patient and/or family/caregivers:

    • Each intervention completed during the daily visit, including the frequency, intensity, and duration, as applicable.

    • Education provided to the patient and/or family/caregivers and how well they understand the education:

      • Instruction regarding equipment the patient is being trained to use and/or issued and the patient's level of independence in using the equipment

      • Home exercise program, with modifications to previously issued program noted clearly and copies of any new exercises issued attached to daily visit note and the patient's level of independence with the new exercises

      • Record of any communication between the treating provider and the patient, family/significant other, caregiver(s), other providers

    • Assessment of the patient's tolerance of/reaction to interventions provided on that date, positive and/or negative, with rationale if negative. It is not enough to state, “tolerated treatment well.” More detail is needed in this area.

    • Any changes in the patient's impairment, activity limitation, and participation restriction status in relationship to the patient's plan of care.

    • All factors that result in a modification of the frequency and/or intensity of intervention and progression of goals.

    • Plan for continued provision of services for the next visit(s) fully documented, including but not limited to:

      • The interventions with objectives

      • Progression parameters

      • Precautions, if indicated.

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It should be ...

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