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.
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
Components of the Daily Visit Note
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: