Daily and Weekly Notes
I know what I want my patients to achieve. I want one to be able to resume PO intake after a PEG placement. I want another to communicate wants and needs with family and staff. I want a new patient with memory loss to adapt to the living environment and daily routine at the SNF and take part in social activities. I use several objective measures to document current level of performance and functional deficits. I conduct patient, family, caregiver interviews in order to learn more about what the patient used to do and what the patient and family hope to gain from skilled therapy. A good patient and family interview combined with standardized testing leads to patient specific goals.
Depending on your company's policies, you may write daily progress notes on every patient, or only in certain circumstances. Regardless of which patients you are required to write daily notes for, the documentation must be specific, objective, and measurable. Which statement do you think is more likely to support reimbursement:
Pt. participated in naming tasks. Followed one-step directions in structured environment.
The patient named pictures of common items with 60% accuracy, when given phonemic and semantic cues. Pt demonstrated ability to follow two-step directions for completion of daily tasks with 50% verbal cues in a low-stimulation environment.
Personally, I view daily notes as beneficial in tracking progress in order to report progress toward short-term goals each week. If I am not required to write a daily note, I follow company policy, but I then have to record accuracy and participation in another format, because I am not going to recall specific accuracy over seven days.
Daily documentation, while not always required, can support ongoing services. The majority of goals I develop are easily measured using a simple system of marking +/- for correct/ incorrect, and a similar system for marking that a cues are given or not given. Most clinicians develop a unique system of marking progress, and there is no one way to document that works for everyone.