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Documentation: How to Show Skill, Progress, and Necessity

Documentation can be daunting, but this fun and information-packed course will help you feel confident in your documentation.

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About this Certificate Program

Spend five hours with Dr. Carole Lewis as she explains and demonstrates succinct documentation skills for everyday note writing. This course will cover initial, progress, daily, and discharge notes and ways to make them skilled and show progress and medical necessity. This is an active course. You will see Dr. Lewis work with a patient and show how to document the patient’s case. In addition, you will learn about the best ways to write quick but comprehensive notes.

Target Audience

Physical therapists, occupational therapists, physical therapist assistants, and occupational therapist assistants

Goals & Objectives

  • Design complete initial and discharge evaluations
  • Describe several key terms that show skill
  • Compare and contrast good notes with bad notes
  • Explain how to document medical necessity
  • Analyze the components of good note writing

What's Included in the Certificate Program

Accredited Online Courses*

5 hours of online video lectures and patient demonstrations.

Case Study Interviews

Recorded Q&A sessions between instructors and practice managers.

Interactive Learning Assessments

Case-based quizzes to evaluate and improve clinical reasoning.

Section 1: Documentation Essentials

5 Chapters

Documentation: Reporting Skill and Progress Part 1keyboard_arrow_down

  • Introduction to DocumentationChapter 1

    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.

  • Discussion With Alice BellChapter 2

    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.

  • Documenting the Initial EvaluationChapter 3

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

  • Documenting Progress in NotesChapter 4

    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.

  • View full course details »

Documentation: Reporting Skill and Progress Part 2keyboard_arrow_down

  • Application to Actual Cases: High LevelChapter 1

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

  • Testing StrengthChapter 2

    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.

  • AssessmentChapter 3

    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.

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Documentation: Reporting Skill and Progress Part 3keyboard_arrow_down


Documentation: Reporting Skill and Progress Part 4keyboard_arrow_down

  • Application to Actual Cases: Lower-Level TreatmentChapter 1

    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.

  • Examining Gait and EnduranceChapter 2

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

  • Home Exercise ReviewChapter 3

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

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Documentation: Reporting Skill and Progress Part 5keyboard_arrow_down

  • Case Study DebriefChapter 1

    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.

  • SummaryChapter 2

    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.

  • View full course details »
Carole B. Lewis


CEU Approved

5 total hours* of accredited coursework.
MedBridge accredits each course individually so you can earn CEUs as you progress.

      Our clinic could not be happier with MedBridge.

Amy Lee, MPT, OCS
Physical Therapy Central

       MedBridge has allowed us to create a culture of learning that we were previously unable to attain with traditional coursework.

Zach Steele, PT, DPT, OCS
Outpatient Physical Therapy & Rehabilitation Services

    MedBridge has created a cost-effective and quality platform that is the future of online education.

Grant R. Koster, PT, ATC, FACHE
Vice President of Clinical Operations, Athletico Physical Therapy

Frequently Asked Questions

Do I get CEU credit?
Each course is individually accredited. Please check each course for your state and discipline. You can receive CEU credit after each course is completed.

When do I get my certificate?
You will receive accredited certificates of completion for each course as you complete them. Once you have completed the entire Certificate Program you will receive your certificate for the program.

*Accreditation Hours
Each course is individually accredited and exact hours will vary by state and discipline. Check each course for specific accreditation for your license.

Do I have to complete the courses in order?
It is not required that you complete the courses in order. Each Certificate Program's content is built to be completed sequentially but it is not forced to be completed this way.

How long do I have access to the Certificate Program?
You will have access to this Certificate Program for as long as you are a subscriber. Your initial subscription will last for one year from the date you purchase.

Sample Certificate

Sample Certificate

Complete this series to receive your certificate.

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Certificate Program
Earn an official certificate of completion from MedBridge.
  • Show the world your achievement
  • Share your course record with peers and employers
  • Show patient and clients your commitment to education

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