No. At a minimum, a daily treatment note should include the patient’s name, the date, a description of the intervention and modalities, along with treatment minutes that were provided, in language that supports the CPT codes that you’re billing. Each entry needs to be physically or electronically signed by the licensee who sees/treats the patient. If the interaction is between the PTA and the patient, the name of the PT who is supervising at the time of the interaction must be included in each entry.
Other elements that might be included in the daily treatment note when determined appropriate and relevant include (but are not limited to) patient’s self-report, objective measurements of functional progress, significant changes to POC and goals, any adverse reaction to treatment, communication or consultation with other providers, significant change in patient’s condition, and/or equipment provided. Your documentation is a communication tool and should convey an accurate picture of your patient’s status to other healthcare providers, third party payers, and/or regulatory agencies.