Documentation Note Types
Documentation is crucial for rehab therapists. In addition to notes that are part of the patient's medical records (evaluative notes, daily notes, and orthosis fabrications), you can create notes that are not part of the medical record (chart notes) that others in your clinic can read.
Medical Record Notes
The following notes are available in the Records section of the patient chart, from the Patient Record Actions drop-down.
Initial Examination (IE) – When a patient starts treatment an Initial Examination is required in each case during the first visit or initial encounter with the patient. You will cover medical history, diagnosis, tests and measurements, problems and goals, and create a Plan of Care (POC), as well as have the option to include treatment and billing codes. Click here for detailed instructions.
Placeholder IE – While technically this isn't its own note type, you should create a placeholder IE when you have a patient that is changing insurance mid-treatment or you are transitioning patients from a different EMR. You do not need to include treatment and billing codes.
Daily Note (DN) – Daily Notes are used for documenting a general therapy session when there were no significant changes to the patient’s diagnosis or status. You can document how they are feeling and what activities and treatments were performed that day.
Progress Note (PN) – Progress Notes are required periodically by insurances, such as every 10 visits for Medicare patients. Use the PN to monitor the status of your patient's progress. You can administer the same tests documented in the IE and take measurements again to determine if treatment needs to be adjusted.
Recertification Note (RN) – Generally, Recertification Notes are used when the patient’s Plan of Care has expired and additional certification is needed from the referring physician to continue treatment. You can perform tests and measurements like on a PN and you can create a new POC in the note to send to the physician.
Re-Examination (RE) – used when there is a significant change in the patient’s status or a new diagnosis code is added. For example, a patient being treated for shoulder pain falls and is re-injured; perform a re-exam to document the current status of the shoulder. Additionally, if a patient has a significant gap in regularly scheduled therapy, you will re-examine the patient to determine the continued need for and direction of therapy.
Discharge Summary (DS) – Discharge Summaries are used when treatment is completed or the patient decides to end treatment, and you are documenting the last visit. Here you will take any final measurements or tests to determine how the patient has improved, discuss any post-rehab goals, and officially discharge the patient from therapy. This is a billed visit.
Quick Discharge (Discharge Note) – A Quick Discharge is used if a patient does not return for treatment and you want to close the case. This is not a billed visit. Briefly document why the case is closed, for example, the patient moves or decides not to return for treatment. If the patient does return for treatment at a later date, we recommend opening a new case.
Note: You can quickly discharge a patient case before you've completed an evaluation if you need to close the case but do not want to inactivate or discharge the patient.
Orthosis Fabrication (OF) – used if you need to make splints or casts for your patient. Create a separate case for each OF.
Re-open Case - Only available once the case has been discharged. When you choose to re-open the case, this action puts the discharge note in pending, allowing you to update whatever you need to. Then, select Discharge Case from the patient record actions dropdown to return the case to Discharged.
Case Note – a brief, non-billable note used to record clinically relevant information that does not necessarily relate to treatment. You can add a Case Note when: a patient needs an explanation for missing work; a student-athlete needs a note stating they can return to sports; a case manager needs your opinion on the patient. Case Notes are officially part of the patient’s medical record and cannot be deleted. However, you can addend case notes.
Cancel/No-Show – a notation that a patient missed an appointment due to: Cancel, No-Show, Scheduling Error, or Re-schedule. Includes the date, and a reason or comment.
Note: Cancels and No-Shows should be noted in the appointment on the therapist's calendar. This will automatically add the notation to the patient’s chart and be counted properly in the Productivity Report and in Analytics reporting.
Chart Notes are available in the Chart Notes section of the patient chart. Select Create Note from the Patient Note Actions drop-down.
Chart Notes are brief notes that are not part of the patient's medical records. Think of them as virtual sticky notes which can be edited or deleted at any time.
- The patient is hard of hearing
- The patient requires a translator
- The patient needs transportation assistance