Family/Caregiver Counseling Note (Rehabilitation)

Date/Time of Service: [Service date; Start time–End time] (Include start/end times when billing timed codes)

Patient: [Name; identifiers per facility policy]

Provider: [Name, discipline, credentials]

Setting: [IRF / SNF / Outpatient clinic / Home health / Acute care / Other]

Modality: [In-person / Telehealth (video) / Telehealth (audio-only phone)]

Encounter Context

Reason for Encounter: [Reason for caregiver counseling/training framed in functional terms tied to the patient's rehabilitation goals] (Reference the current plan of care and identify the functional problems addressed.)

Participants: [Patient present: Yes / No] (If patient not present, briefly state clinical reason) | [Caregiver name(s) and relationship(s)] (Identify primary vs. secondary caregiver if applicable)

Consent: [Consent statement] (If patient present, document patient agreement or opportunity to object. If patient not present, explicitly document that the patient or legal representative provided consent for caregiver training and discussion of care needs. Required for Medicare CTS billing.)

Interpreter: [Language, interpreter modality, interpreter ID] (Only include if interpreter used)

Intervention

(Document caregiver training/counseling with sufficient detail for another clinician to replicate. Include technique/strategy taught, precautions and safety limits, materials provided, and method of instruction. Include brief skilled clinical reasoning for highest-risk items.)

• [Skill/Topic]: [Technique and steps taught] | Precautions: [Safety limits, stop rules, supervision level] | Method: [Verbal instruction / Demonstration / Return demonstration / Role-play] | Materials: [Handouts, checklists, device instructions provided] | Skilled reasoning: [Brief rationale for why skilled training was required]
• (Repeat for each additional skill/topic addressed)

(If session was supportive counseling without skills training:)

• Counseling focus: [Caregiver stress, coping, role adjustment, community resources, expectations, discharge planning]
• Referrals/resources: [Social work / behavioral health / caregiver support / respite services / case management]

Caregiver Response

• Engagement: [Objective description of participation, questions asked, adherence to instruction]
• Learning verification: [Teach-back / Return demonstration / Scenario testing] (Required for safety-critical skills; summarize performance)
• Performance: [Objective accuracy and cueing needs; number/type of cues, errors corrected, safety awareness]
• Remaining gaps: [Skills or concepts needing reinforcement; barriers identified]
• Assessment limitations: [Competence not assessable due to modality/environment] (Only include if applicable; note in-person reassessment planned)

Assessment

[2–4 sentence narrative summarizing caregiver capabilities demonstrated, remaining gaps with impact on patient safety and outcomes, and how today's intervention advances the rehabilitation and discharge plan] (If patient was absent, state whether caregiver-only format was clinically appropriate.)

Plan

• Caregiver homework: [Specific tasks to practice before next session; frequency; safety checks]
• Next session: [Skills/topics for next training; location; required participants]
• Team actions: [Equipment orders, referrals, home safety evaluation, interdisciplinary coordination, plan of care updates]
• Safety red flags reviewed: [Key red flags and escalation instructions: when to contact clinic, MD, or 911]
• Outstanding information: [Unknown/not assessed details with follow-up owner and timeframe] (Only include if applicable)

Time and Billing

Total training/counseling time: [Minutes] | Code(s)/Units: [CPT code; units billed] (Ensure time meets CMS timed code requirements effective January 2025)