What to Record for Assessment and Plan of Treatment in All Settings
Medical History
- Date of onset/exacerbation
- Prior functional status
- History of previous treatment and outcomes, if any
- Homebound Status (home health only)
Plan of Treatment
- Type of therapy/procedures
- Frequency and duration
- Diagnosis
- Functional goals (short-term)
- Outcome (long-term)
If your facility is accredited by JCAHO, there are additional requirements that must be met. Check with your facility administrator to review the JCAHO accreditation manual or discuss your facility's compliance plan.
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