Documentation

Reporting Skill and Progress


Third party payers such as CMS and private insurers believe that documentation is a tool that can drive good patient care. Therapists typically see documentation as a necessary evil that takes time away from patient care, but allows them to get paid.

The key to indisputable documentation is to demonstrate your skill, record progress, and show medical necessity. Carole Lewis shows you how to do all 3 without taking excessive amounts of time from patient care.

She uses real patient examples, hilarious interactive vignettes, shortcuts, and skilled terminology handouts and flow sheets to help clinicians become more efficient and effective documenters.

Managed care does not equal patient denials. But if your documentation has resulted in denials, Dr. Lewis explains how to fight them effectively.

Phrases like “continue as above” or “patient tolerated treatment well” are not just a waste of space. They’re red flags. Learn the correct and easy phrases that demonstrate your skill, record progress, and show medical necessity without increasing your documentation time. Correct phrases will save you hours of time and help your patients to get the care they need because your notes justify it.

Dr. Lewis is clear and concise, but she also uses humor to get her points across.  The segment featuring a mock Self-help Group for Poor Documenters is hilarious.

Stop taking courses that “should” on you and take this one that enables you to create better initial, progress, daily and discharge notes in a practical fashion.

The handouts will make your documentation incredibly easy and indisputable. The handouts include:

  • Documentation skilled terminology sheet
  • Functional test norms
  • 3 case studies
  • Examples of initial evals and re-evals
  • Daily notes
  • Discharge summaries
  • Home exercise programs
  • Plan of care and progress flow sheet
  • Recommended documentation equipment list
What participants are saying . . .

“I can now reflect a higher level of care in my documentation.”

“I’m going to share with others in my facility how to incorporate skilled terminology more concisely”

“Loved both of the case examples….very helpful in confirming how much can be done for both high and lower functioning patients.”

“The video of Dr. Lewis performing the initial evaluations with the feedback afterwards- excellent! The treatment plan and how she carried out that plan from day one & as the patient progressed was great. Loved the ongoing dialog explaining what she was doing & why. Appreciated her positive demeanor.”

  1. Compile an arsenal of helpful tools to make documenting skill and progress easier and more user friendly
  2. Appraise the quality of initial, progress and discharge notes
  3. Design drop down menus that reflect therapist skill in daily notes
  4. Compose an initial progress or discharge note that contains excellent examples of skill and progress
  5. Adapt one’s current methods to incorporate useful tools and words that demonstrate skill and progress

  • Introduction and pre-test (7 min)
  • Documentation skill (38 min)
  • Documenting initial evaluation (24 min)
  • Case study 1 high level patient (34 min)
  • Case study 2 low level patient initial eval (61 min)
  • Case study 2 low level patient treatment (56 min)
  • Take home message (10 min)
  • Application assignment (Choose ONE) (45 min):
    • Design aspects of a drop down electronic reporting system OR
    • Improve documentation for a case study
  • Conclusion, post-test & course evaluation (7 min)

Handouts for Documentation

  • Case 1 Documentation of Mr. X
  • Case 2 Initial Eval of Ms. B
  • Case 3 Initial Eval of Mr. QT
  • Initial Eval Ms. P
  • Daily Notes for Ms. P
  • IE and Discharge Summary Ms. P
  • Home Exercise Program for Ms. P
  • Ms. P Plan of Care and Progress Flow Sheet
  • Boissonnault and Badke Health History
  • Initial Evaluation Fran
  • Home Exercise Program for Fran visit 1
  • Daily Notes for Fran
  • Fran Plan of Care and Progress Flow Sheet
  • Re-Evaluation Fran
  • Home Exercise Program for Fran visit 2
  • Initial Eval and Re-Eval Template
  • Plan of Care and Progress Flow Sheet Template Tall
  • Plan of Care and Progress Flow Sheet Template Wide
  • Plan of Care and Progress Flow Sheet Template for Balance and Shoulder Problem
  • Documentation – Skill Terminology
  • Recommended Documentation Equipment List
  • Documentation Case Study Project
  • Documentation Electronic Menu Project
  • Documentation References

Upon completion of the course, a certificate of completion for 5 contact hours of educational credit will be awarded.

PHYSICAL THERAPY

Great Seminars Online (GSO) is an Approved CE Provider for PTs and PTAs in CA, IL, NM, NY, OK, TX.

This course has received CE approval from the following state licensure boards or associations:  AR, FL, LA, NV, NJ, OH.

This course meets the guidelines for CE approval in: CO, CT, ID, IA, KS, ME, NH, NE, SD.

This course has been accepted for CE credit by these states because it has been approved by another state’s board or association: AK, AL, AZ, DE, GA, HA, IN, KY, MA, MI, MN, MS, MO, MT, NC, ND, OR, PA, RI, SC, TN, UT, VT, VA, WI, WY, WA.

INDIVIDUAL APPLICATIONS

If you do not see your state listed, please visit your state board or association’s website and request information for an individual application.

OCCUPATIONAL THERAPY

This course has received CE approval from the following State licensure association: FL

Great Seminars Online courses meet occupational therapy state licensure renewal requirements including but not necessarily limited to these states:   AL, AR, AZ, CO, CT, GA, ID, IA, KY, MI, MN, MO, MT, NE, NH, NM, NV, NY, NC, ND, OH, OK, OR, RI, SC, TN, TX, UT, VA, WA, WV, WI, WY

5 Contact Hours - $149.00



Your Instructor

Dr. Carole B. Lewis, PT, DPT, MSG, MPA, PhD, GCS, GTCCS, TRC/CTR, FSOAE, FAPTA



Unlimited access: Once you have purchased a course, you have unlimited access. You may stop and start and rewind as often as you wish. The course will remain in your cart and you are free to review the content at any time. However, continuing education credit is only available for the year in which you purchase a course.
Accessing this course: Click on “Enroll Now.” Once you have submitted the registration information, click “Order Now”. You will then see a “Thank You” message. You will be emailed a username, password and information on how to log in to our learning management system (LMS).
Course Format: Online video course
Target Audience: Physical Therapist, Physical Therapist Assistant, Occupational Therapist, Occupational Therapist Assistant.