Progressive Notes

Goal driven therapist documentation

Sam Wang, MD

Courtney Wang, MHS, OTR/L

  - Clinical Director for Galaxy Brain & Therapy Center

 

Ann Arbor, MI

swang@galileomd.com

notes.progressivenotes.com

use your @spalding.com account

Documentation

If you didn't document it, it didn't happen

If it didn't happen, you dont get reimbur$ed

Subjective

SOAP style

Objective

Assessment

Plan

What's said / conveyed

Info you observed / collected

Your clinical summary

Plan for future treatment sessions

Subjective

Progressive Notes style

Objective /

Assessment

Plan

What's said / conveyed

Skilled education / treatment and response to therapy

- Make sure you're treating based off your goals

Plan for future treatment sessions

Progress towards goal

- Show progress towards goal to justify treatment

notes.progressivenotes.com

Evaluation

Daily note

Daily note
Daily note

Progress note

Patient

Treatment

goals

notes.progressivenotes.com

Daily note

Daily note
Daily note

Treatment

goals

notes.progressivenotes.com

Student

starts/edits local draft

 

- eval note

- daily note

- progress note

Save &

Preview

(1 & 3)

Complete & Bill

(4)

Faculty reviews

(2)

notes.progressivenotes.com

(1)

(2)

(3)

(4)

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Complete & Bill

(Publicly visible)

notes.progressivenotes.com

Patient List

- starring floats a patient to top of group

- create in right group

 

 

Patient

- patient demographics as part of header

- therapy recommendations entered once

 

Clinical scenario

36yo female with recent CVA 6 weeks ago and residual left sided weakness

- Post stroke - a simple effective way to put on and take off shirt:

 https://www.youtube.com/watch?v=vZsBU51NQlQ