Therapists must be able to paint a clear picture of the patient's abilities, limitations, and how these impact their daily life. Here are some specific tips to help you write effective functional assessments.
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It is the practice of completing notes and charting while you are still in the patient's home. This doesn't mean ignoring the patient or their family; it means using the natural pauses and transitions within a visit to your advantage.
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Properly documenting medication and health teaching is vital. It creates a clear record of the patient’s understanding and ability to manage their health, justifies services for reimbursement, and, most importantly, reduces the risk of adverse events.
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Home health visit notes often lack the objective detail needed to truly demonstrate skilled care and patient progress. Avoid vague terms like "tolerated well" or "wound healing."
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