A few weeks ago we made changes to therapy visits, which were previously called PT Progress Notes and OT Progress Notes. Over the years we have spent considerable time changing therapy assessments and therapy visits trying to come up with one form that would satisfy all agencies. Some agencies wanted extensive data collection, others wanted less data collection.
What we did was come up with three different formats for the physical and occupational therapy visits records. When you open up the data collection screens there is a “Type of Note” drop-down option to classify the visit as a Visit Note, Progress Note, or Functional Assessment. The visit note collects the least amount of data, the progress note collects more data, the functional assessment collects the most amount of data and can be used as a therapy assessment but it’s attached to the visit. Prior to this change the assessment had to be completed separate from the visit. You may want to open up a therapy visit, change the type of note, and browse the different data entry screens to see the differences to determine which formats work best for your situations.
At the request of several of our agencies we a working on completing a speech therapy assessment along and speech therapy visits. We will be taking the same approach with speech therapy.