Does each daily note need to address short and long term goals?
The purpose of treatment notes is simply to create a record of all treatments and skilled interventions that are provided and to record the time of the services in order to justify the use of billing codes on the claim. Documentation is required for every treatment day, and every therapy service. The Treatment Note is not required to document the medical necessity or appropriateness of the ongoing therapy services. Documentation of each Treatment shall include the following required elements: • Date of treatment • Identification of each specific intervention/modality provided and billed, for both timed and untimed codes • Total timed code treatment minutes and total treatment time in minutes • Signature and professional identification of the qualified professional who furnished or supervised the services and a list of each person who contributed to that treatment Documentation of each Treatment may also include the following optional elements to be mentioned only if the qualified profe
The purpose of treatment notes is simply to create a record of all treatments and skilled interventions that are provided and to record the time of the services in order to justify the use of billing codes on the claim. Documentation is required for every treatment day, and every therapy service. The Treatment Note is not required to document the medical necessity or appropriateness of the ongoing therapy services. Documentation of each Treatment shall include the following required elements: • Date of treatment • Identification of each specific intervention/modality provided and billed, for both timed and untimed codes • Total timed code treatment minutes and total treatment time in minutes • Signature and professional identification of the qualified professional who furnished or supervised the services and a list of each person who contributed to that treatment Documentation of each Treatment may also include the following optional elements to be mentioned only if the qualified profe
