Therapy Documentation: Telling the Rehab Story from Once Upon a Time to the End

Course Description:

Even though you’ve heard the terms skilled, reasonable, and medically necessary, are you unsure whether your documentation truly meets these Medicare requirements? Reviews and audits are commonplace; often, therapy services are denied when documentation is cited as lacking essential components. Therapists want their patients to achieve the best possible outcomes and be reimbursed for services provided – learning to identify and understand key documentation components from evaluation through discharge can help tell the therapy story, ultimately leading to a rewarding conclusion.

This course will review all elements of an episode of care, focusing on providing and integrating skilled, reasonable, and medically necessary services into the evaluation, progress notes, daily notes, and the discharge summary. Strategies for incorporating standardized testing, caregiver training, and the use of evidence-based treatment will be discussed to ensure the best possible patient outcomes.

We will analyze documentation examples and learn to differentiate between skilled and unskilled verbiage. We will discuss the difference between a maintenance program and a rehabilitative therapy program – when documenting, therapists will understand how to distinguish between the two.

Excellent patient outcomes begin with skilled documentation. This training aims to equip therapists with the most essential tools, strategies, and examples needed to build a solid foundation for patient and therapist success.