RT Book, Section
A1 Kettenbach, Ginge
A1 Schlomer, Sarah L.
A1 FitzGerald, Jill
SR Print(0)
ID 1180746647
T1 Tips for Note Writing for Third-Party Payors
T2 Writing Patient/Client Notes
YR 2016
FD 2016
PB F. A. Davis Company
PP New York, NY
SN 9780803638204
LK fadavispt.mhmedical.com/content.aspx?aid=1180746647
RD 2024/04/16
AB Include  the  current  medical  diagnosis  and  any  relevant  secondary  medical  diagnoses  or  test  results.  The  relevant  secondary  medical  diagnosis  can  help  justify  the  need  for  examination  of  a  patient's  functional  level,  even  if  the  patient  does  not  need  prolonged  OT  or  PT.The  onset  of  the  current  medical  diagnosis  and  the  date  that  therapy  began  are  essential  to  the  initial  evaluation  note  and  will  also  be  referred  to  in  the  re-evaluation/progress  and  D/C  note.Do  not  list  irrelevant  information.  Information  from  the  patient  or  significant  other(s)  should  help  demonstrate  the  need  for  therapy.When  reporting  complaints,  keep  the  complaints  brief  and  to  the  point.  What  does  the  patient  see  as  his  or  her  biggest  complaint  or  concern?  How  does  this  complaint/concern  tie  into  patient  performance  of  activities  and  participation  (if  the  complaint/concern  itself  is  not  functional)?Have  the  patient  rate  his  or  her  complaints  on  a  scale.  Subjective  information  put  on  a  type  of  scale  or  measured  with  an  evidence-based  tool  can  be  used  to  re-evaluate  the  patient's  progress  over  the  course  of  therapy.  A  pain  scale  is  one  example.  Functional  abilities  at  home  and  the  amount  of  assistance  the  patient  required  to  complete  them  (e.g.,  the  number  of  people  needed)  is  another.  Subjective  information  put  on  a  type  of  scale  or  measured  with  an  evidence-based  tool  can  be  used  to  re-evaluate  the  patient's  progress.  Use  a  quality-of-life  scale  if  possible.Avoid  listing  nonspecific  complaints  in  progress  notes  that  are  the  result  of  possible  patient  discouragement.  Statements  such  as  “I  don't  think  I'm  doing  very  well”  may  serve  as  a  red  flag  to  the  reviewers  and  may  not  be  validated  by  the  results  of  objective  tests  and  measures.Do  list  the  patient's  level  of  functioning  prior  to  the  onset  of  his  or  her  current  diagnosis.  This  can  help  justify  the  need  for  therapy  in  the  case  of  a  chronic  illness.  It  can  also  justify  the  need  for  teaching  by  the  therapist.  (For  example,  a  patient  who  has  never  used  a  walker  before  needs  instruction  in  its  proper  use.)Do  briefly  describe  the  patient's  living  environment,  social  history,  and  employment  status  and  environment.  Does  the  patient  live  alone?  Who  will  be  available  and  for  what  duration  to  care  for  the  patient,  if  needed?  Are  there  steps  present,  to  access  the  patient's  residence  or  bedroom  and  main  bathroom  and  is  there  a  handrail?  Are  the  steps  essential  for  the  patient  to  ambulate?  What  is  the  distance  from  the  bed  to  the  bathroom,  to  the  kitchen,  and  so  forth?  Are  the  surfaces  on  the  floors  carpeted,  tiled,  linoleum,  or  hardwood,  and  are  throw  rugs  present?  Are  there  grab  bars  in  the  bathroom  around  the  toilet  or  tub?  Can  a  wheelchair  fit  through  the  doorways  and  turn  in  the  rooms,  if  needed?Briefly  list  any  relevant  history  from  the  patient  under  the  appropriate  subcategories.  Has  the  patient's  functional  status  declined  recently?  If  so,  why?  Include  whether  the  patient  has  received  therapy  before,  why,  and  when.  Has  the  patient  ever  used  an  assistive  device?  Why  and  when?  Does  the  patient  own  an  assistive  device  or  ...