Feb
28
Written by:
SpeechTree
2/28/2011 5:24 PM
As therapists, we are all aware of the importance of good clinical documentation as well as how it reflects back on each of us as a competent professional. While we are all busy and many times, thinking about what we want to say or do next, it is imperative that we provide good clinical documentation through our progress/daily notes and evaluation reports. There are several aspects to keep in mind while documenting clinical information in our progress/daily or evaluation reports.
Every therapist has seen at least one report that lacks competent relevant insight into the child’s abilities and skills. This provides a view of the therapist as being someone who is not adhering to professional standards and appearing to be below par. This is not how we want to be viewed by other professionals or families. Good clinical documentation is very important not only as it provides a representation of your professional skills but it is also very important for the parents and for billing purposes.
When writing progress/daily notes as well as reports, you should make sure to include pertinent information in relation to current goals and level of progress in meeting these goals. At times, you may begin providing services to a child who has been waiting for services for several months; therefore, the evaluation report may no longer reflect the child’s skills and/or level of performance. As a professional, you need to observe current skills and adapt/change the original goals to reflect his current level of performance.
Another important aspect to remember is that the insurance companies do require goals incorporated in treatment plans and annual evaluation reports when asked to cover payment for therapy services. Clear and precise documentation regarding the child’s skill and performance level will insure timely response from the insurance companies as coding will not be problematic. Writing informative progress/daily notes is basic to maintaining accurate records for a child and aids in preparing annual/evaluation reports as well as providing requested information to insurance companies.
As we all know, the written word is as powerful as meeting in person. Ensure that you are seen as a competent professional through your written documentation. We do not know how many people or who will see our notes and reports. However, all of us do want to be seen in the best possible light as a highly qualified and competent professional.