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Best Practices in Documentation for Rehab Providers
Documentation is a critical component of therapy services. Your documentation is used to communicate with other healthcare professionals, evaluate the effectiveness of treatment, and substantiate billing by justifying the care provided. Individuals who review your documentation in the medical record will never see the therapy sessions, so you have to “tell the story” by including the necessary components to justify services for reimbursement. This course covers general guidelines for documentation, components to improve documentation, and special considerations. Practical examples are provided to help you incorporate best practices into your documentation.
Identify five required components of therapy goals.
Determine at least three ways to improve documentation through the use of evidence-based practice and demonstration of skilled need and medical necessity.
Recall at least four documentation requirements across all settings.