Using Daily Assessments to Show Skilled Care
How to Use Daily Assessments to Show Skilled Care
In your daily treatment note, you need to highlight hindrances impacting your clients progress and how you are addressing these hindrances.
And this does not have to be as hard or time consuming as you think.
To make this easy break it into 3 sections:
1. Start with what your treatment focused on that day such as:
- technique
- balance
- endurance
- vitals
- strength
- ROM
- a specific task
- ambulation technique
- transfers
2. How did your client respond that day such as:
- progression with...
- regressed with....
- modification secondary to ...
- added ...
- removed...
- facilitated ...
3. Explain your client's response to the changes that were made and how you are going to work on this in the future.
Remember as long as you can show why your treatment session required your skill and a caregiver couldn't do it you can continue to treat your client.
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