Clinical Documentation - PT Assistant

Documentation 207

Documenting Activities


1.0

  • Define activities and function
  • Discuss the factors involved in deciding which activities should be included in physical therapy documentation, including consideration of benchmark activities
  • Identify and classify various aspects of documenting activities
  • Appropriately categorize activities of daily living and instrumental activities of daily living
  • Document activities using a skill-based framework

Joanne Brown, MS, OT, CHT

Case Studies
Downloadable Course in PDF
Text

$18.00 USD

Documentation 206

Documenting Reason for Referral: Participation and Social History


1.0

  • Describe the components of documenting participation, social history, and general health status
  • Describe the usefulness of standardized outcome measures for documenting participation
  • Describe the process of conducting an interview to obtain information pertaining to level of participation, social history, and general health status
  • Document these components with accuracy and specificity
  • Read and analyze clinical examples emphasized with case examples

Joanne Brown, MS, OT, CHT

Case Studies
Text

$18.00 USD

Documentation 205
Documenting Reason for Referral: Health Condition and Participation

1.0

  • Identify and classify various aspects of documenting reason for referral, including a patient’s background information, health condition, medications, past medical history, social history/participation, and prior functional status
  • Explain the 3 key elements of describing a patient's current health condition
  • Discuss the implications of direct access for documenting medical diagnoses
  • Describe the process of conducting an interview to obtain information pertaining to gathering history data
  • Appropriately document elements of reason for referral based on case scenarios

Joanne Brown, MS, OT, CHT

Case Studies
Downloadable Course in PDF
Text

$18.00 USD

Documentation 204

Documentation in Pediatrics


1.0

  • 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

Downloadable Course in PDF
Text

$18.00 USD

Documentation 203

Documenting the Plan of Care


1.0

  • 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
Text

$18.00 USD

Documentation 202
Developing and Documenting Effective Goals

1.0

  • 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
Text

$18.00 USD

Documentation 201

Payment Policy and Coding


1.0

  • 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

$18.00 USD