Certificate Program
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
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Design complete initial and discharge evaluations
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Describe several key terms that show skill
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Compare and contrast good notes with bad notes
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Explain how to document medical necessity
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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.
Certificate Program overview
Section 1
Documentation Essentials 5 ItemsDocumentation: Reporting Skill and Progress Part 1 Course
Chapter 1: Introduction to Documentation
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.
Chapter 2: Discussion With Alice Bell
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.
Chapter 3: Documenting the Initial Evaluation
This chapter reviews three initial evaluation note examples with recommended improvements for writing more detailed documentation of patient care.
Chapter 4: Documenting Progress in Notes
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.
Documentation: Reporting Skill and Progress Part 2 Course
Chapter 1: Application to Actual Cases: High Level
This chapter introduces a high level patient who performs posture and balance tests in video demonstrations.
Chapter 2: Testing Strength
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.
Chapter 3: Assessment
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.
Documentation: Reporting Skill and Progress Part 3 Course
Chapter 1: Application to Actual Cases: Lower-Level Initial Evaluation
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.
Chapter 2: Lower-Level Patient Evaluation
This chapter demonstrates a balance and walking test as well as an endurance test with the patient.
Chapter 3: Results
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.
Documentation: Reporting Skill and Progress Part 4 Course
Chapter 1: Application to Actual Cases: Lower-Level Treatment
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.
Chapter 2: Examining Gait and Endurance
This chapter works on various aspects of gait training with the patient, including incorporating the patient's goal to dance, to increase step length.
Chapter 3: Home Exercise Review
This chapter reviews the home exercise program with the patient and explains incorporating the exercises into daily functional tasks and activities.
Documentation: Reporting Skill and Progress Part 5 Course
Chapter 1: Case Study Debrief
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.
Chapter 2: Summary
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.
Instructors
Carole B. Lewis
PT, DPT, GCS, GTCCS, MPA, MSG, PhD, FAPTA
CEU approved
5
total hours*
of accredited coursework.
Medbridge accredits each course individually so you can earn CEUs as you progress.
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Browse PlansFrequently asked questions
Everything you need to know about Certificate Programs.
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.
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.
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.
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.
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