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Clinical Documentation - Occupational Therapist


Documentation 204

Documentation in Pediatrics


1.0

$19.00 USD

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  • Describe the laws governing documentation in early intervention and school-based settings in the United States
  • Identify commonly used standardized assessments in early intervention and school-based settings
  • Document components of early intervention evaluations and session notes, which are family-centered, child-specific, routines-based, and aligned with the natural environment
  • Document components of school-based evaluations and session notes, which are child-centered and specific to the school setting
  • Create goals for a pediatric client based on best practice standards, including making goals child-centered, context-specific and addressing specific tasks or functional activities

Joanne Brown, MS, OT, CHT

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Documentation 203

Documenting the Plan of Care


1.0

$19.00 USD

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  • Identify and describe the components of documentation of the plan of care
  • Appropriately document a plan of care as part of an initial evaluation
  • Discuss the importance of documenting informed consent

Joanne Brown, MS, OT, CHT

Downloadable Course in PDF
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Documentation 202
Developing and Documenting Effective Goals

1.0

$19.00 USD

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  • Differentiate between goals and outcomes
  • Describe the important aspects of writing goals at the participation, activity, and impairment levels
  • Distinguish between short-term and long-term goals
  • Describe the essential components of a well-written functional goal Identify poorly written goals and make modifications to goals
  • Appropriately document participation and activity goals for a written report

Joanne Brown, MS, OT, CHT

Downloadable Course in PDF
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Documentation 201

Payment Policy and Coding


1.0

$19.00 USD

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  • Provide a brief overview of health care reform and its impact on physical therapy and third-party payers in context of reform environment
  • Describe Medicare settings that outpatient services are provided in, as well as the characteristic policies and key compliance elements required by Medicare and other third-party payers
  • Outline Medicare guidelines for documenting skilled therapy services
  • List the components of documentation for Medicare, including initial evaluations including plan of care, progress notes, session notes, reevaluations, and discharge summaries
  • Understand basics of functional limitation reporting, physician quality reporting system and diagnosis coding and CPT coding for billing and payment purposes
  • Summarize guidelines for CPT coding that may facilitate payment for services and minimize payment delays and denials

Joanne Brown, MS, OT, CHT

Downloadable Course in PDF
Text