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Introduction

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Congratulations! You have mastered the skill of documenting patient care. Now that you have mastered the skills required for documentation, a brief discussion of applications of documentation skills is appropriate. This section focuses on some unique components that are used in specific forms of therapy documentation. Chapter 21, Writing the Daily Visit or Encounter Note, is an application of the documentation skills that you have already learned, with specific focus on the note components that should be present in each daily visit note. Chapter 22, The Medicare Therapy Cap, KX Modifiers, and Functional Limitations Reporting (G-Codes), reviews specific information that you need to know to document skilled treatment provided to Medicare recipients. Chapter 23, Applications and Variations in Note Writing, discusses some alternatives to the Patient/Client Management Note and SOAP Note formats, including a brief discussion about computerized documentation.

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