Best Practice Documentation For Writing Your Daily Treatment Notes

Daily Treatment Notes

Let’s go back to the basics here.  Every time we work with a patient, we open a daily treatment note.  Whether you have been practicing as an OT or PT for several years or you are just getting started, it is important to review the basics of writing a daily treatment notes.

It’s easy to get in the habit of checking or clicking the same activities each session. However, this is not skilled and it is not best practice.

Show Your Skill

To support skilled care in your daily treatment note you need to document:

• assist level
• cues
• comments
• support your billing by showing there is an appropriate volume of interventions
• include time or set/reps of each activity to support billing

Dig Deeper

• connect your activity to your goals
• link education to a functional goal
• monitor vital signs
• record subjective comments
• keep your treatment client-centered

I hope you can all use this refresher to improve your documentation.  Let us know your biggest struggle with documentation by commenting on our instagram page @thenoteninjas

Do you know other therapists that could use more ideas for client-centered treatment? Make sure to share this post and follow us and tag them on Instagram www.instagram.com/thenoteninjas

And if you haven't yet, make sure to download our FREE PDF with skilled care documentation tips HERE!

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