This chapter introduces electronic documentation and how therapists can learn to make their documentation better in a way that works for them. We will discuss the benefit of using evidence and norms in notes to show skill. A skit demonstrating how to improve documentation of the skill you've added to your patient's care is included.

This chapter features a discussion with Doctor Alice Bell, who talks about the importance of documentation in treatment as well as how a therapist's value is demonstrated through documentation.

This chapter reviews three initial evaluation note examples with recommended improvements for writing more detailed documentation of patient care.

This chapter discusses documenting progress in your notes. A skit demonstrating how to improve documentation of the progress your patient demonstrates during your sessions is included.

This chapter introduces a high level patient who performs posture and balance tests in video demonstrations.

This chapter follows the same high level patient who is moved to a treatment table to test their dynamometry strength. Also included are manual muscle strength testing, plank testing, and measuring range of motion.

This chapter looks at the assessment of the results from the tests in Chapter 1 and 2. How to document the skill and progress for this high level patient is shown.

This chapter introduces a low-level patient who is administered the Patient-Specific Functional Scale. She provides her medical history and describes her previous rehab experience as well as her current exercise program. Modified strength tests for the patient's specific needs are discussed.

This chapter demonstrates a balance and walking test as well as an endurance test with the patient.

In this chapter, we review the scores from the tests in chapters 1 and 2 with the patient and show her exercises she can incorporate into her routine to improve lower-scoring areas.

This chapter revisits the low-level patient from Part 3 of this series to review the home exercise program prescribed after her initial evaluation. The patient performs more balance exercises and is taught proper positioning and timing for muscle stretching. TheraBand exercises to improve muscle strength are introduced.

This chapter works on various aspects of gait training with the patient, including incorporating the patient's goal to dance, to increase step length.

This chapter reviews the home exercise program with the patient and explains incorporating the exercises into daily functional tasks and activities.

This chapter reviews the low-level patient's results in Part 3 and 4 of this series and explains how to best document the skill and progress during those sessions in your notes.

This chapter summarizes the five-part series and the importance of documenting both skill and progress in your notes. Tips for tests and equipment you can incorporate into your sessions are included.