Documentation for Rehab Therapy

This course is designed to train clinicians in improved documentation techniques regardless of what specific forms or intermediary requirements each individual provider utilizes.  Documentation is a permanent record of what services occurred during therapy sessions.  The record tells a story from start to finish of what the deficits were; what skilled interventions were provided; the patient’s response to the interventions; modifications to the plan of care; patients progress and status at discharge.  Documentation must be captured in a way that stands the test of time even after patients and therapists have moved on.  Clinicians have a professional responsibility as well as legal liability for documented “proof” of services rendered and billed.  One of the biggest reasons for denials of therapy services is based on a lack of medical documentation to support the claim (or charges).  Even though documentation is critical to reimbursement and supporting services provided, it is often the least compliant.

After completing this course you will be able to:

•    Increased knowledge of documentation requirements for third-party reimbursement
•    Understanding how each piece of documentation builds a basis and rational for therapy intervention
•    Learn how to write skilled evaluations, plans of care, treatment encounter notes, progress reports, justification statements, and discharge summaries
•    Learn the difference between skilled and non-skilled documentation
•    Understand how to provide documentation that supports reimbursement