"You do not need to address each goal in your daily note. Focus on what you did that was skilled."
This is a direct quote from our DOR to me. I really like our DOR, she is fair, concise, and a great clinician but I didn't get what this meant.
So I asked, "How can we document progress and attainment of goals if we don't address them?"
After several more short conversations throughout the day and confusion about a progress note that was due it was decided (I assume) that I should address goals in the daily notes.
The confusion about the progress note was a goal was not addressed in the daily notes so what should be written? Should we write "not assessed", ignore it or make it up? My contention is that if it was not documented in the daily notes for the last two weeks it was not addressed by anyone and I would have written that is was not assessed. This did not sit well with the department and the PT decided to write the progress note. I hope she didn't make it up.
Help me out here. Do we address goals in the daily notes or have I been doing this wrong for the last 14 years?