$60.00

i 1.25 Hours

Course Overview

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 will cover general guidelines for documentation, components to improve documentation, and special considerations. Practical examples will be provided to help you incorporate best practices into your documentation.

The content in this course is applicable to occupational therapy, physical therapy, and speech-language pathology professionals in post-acute care settings.

About the Course Author

Ann Elsasser-Root holds a Doctor of Physical Therapy degree from the University of Pittsburgh. She has experience working as a physical therapist in multiple care settings, including skilled nursing, independent living, inpatient rehab, and outpatient orthopedic and neurology. Ann has a strong manual therapy background and has completed additional training in geriatric care, kinesiotaping, vestibular rehabilitation, and McKenzie MDT for the lumbar spine. She is most passionate about treating the older population to improve quality of life and maximize functional independence. As a curriculum designer for Relias, Ann enjoys being able to combine her clinical knowledge with her interest in research and staying up-to-date with changes and advances in the field of rehabilitation. Ann Elsasser-Root, PT DPT has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.

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Accreditation Information

Certificates provided by accrediting body (56 Match)

  • American Occupational Therapy Association

    0.10HOURS


    Relias LLC is an approved provider of continuing education for occupational therapists by the American Occupational Therapy Association. AOTA does not endorse specific course content, products, or clinical procedures.


    Course approval ID# Blanket Providership Approval Pre-2020. This Distance Learning-Independent is offered at 0.1 CEUs Introductory,Category 3.

  • Arkansas State Board of Physical Therapy

    1.25HOURS

    This course is approved by the Arkansas State Board of Physical Therapy and offered to PTs and PTAs for 1.25 contact hours.
  • Iowa Board of Physical and Occupational Therapy

    1.25HOURS

    The Iowa Bureau of Professional Licensure accepts Continuing Education hours obtained by completing online training courses related to the practice of physical therapy. This course is approved by the Physical Therapy Board of California and offered to PTs and PTAs for CEUs. This activity is approved for 1.25 contact hours. Disclaimer: It is the learner's responsibility to determine whether or not this course meets the specific renewal requirements established by your licensing board.
  • Massachusetts Board of Registration in Allied Health Professionals

    1.25HOURS

    This activity is approved for 1.25 contact hours.
  • Arizona Board of Physical Therapy Examiners

    1.25HOURS


    Arizona State Board of Physical Therapy (CEBroker Provider #50-290)

    This activity is approved for 1.25 contact hours.
  • Colorado Physical Therapy Licensure

    1.25HOURS

    The Colorado State Physical Therapy Board accepts Continuing Education courses as relevant to the licensee’s practice as a physical therapist and pertinent to his/her Learning Plan and goals. This course meets the requirements for Category I credit. This activity is approved for 1.25 contact hours.
  • Connecticut Physical Therapy Licensing

    1.25HOURS

    The Connecticut State Board of Examiners for Physical Therapists accepts internet-based and distance learning opportunities provided such coursework is related to the practice of physical therapy. This course is approved by the Physical Therapy Board of California and offered to PTs and PTAs for CEUs. This activity is approved for 1.25 contact hours.
  • Florida Board of Occupational Therapy

    1.25HOURS


    Florida Board of Occupational Therapy (CEBroker Provider #50-290)

    Occupational Therapists will receive 1.25 contact hours.
  • Idaho Physical Therapy Licensure Board

    1.25HOURS

    The Idaho Physical Therapy Licensure Board accepts Continuing Education courses sponsored by any section or chapter of the American Physical Therapy Association. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX. This activity is approved for 1.25 contact hours.
  • Illinois Division of Professional Regulation of Physical Therapists

    1.25HOURS

    Relias LLC is an Illinois Physical Therapy Continuing Education Sponsor, number 216.000290. This activity is approved for 1.25 contact hours.
  • Indiana Physical Therapy Committee

    1.25HOURS

    The Indiana Physical Therapy Committee accepts Continuing Education courses approved by any state physical therapy association. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX. This activity is approved for 1.25 contact hours.
  • Kentucky Board of Physical Therapy

    1.25HOURS

    The Kentucky Board of Physical Therapy accepts Continuing Education courses approved by the American Physical Therapy Association and its affiliate components. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX.
  • Louisiana Physical Therapy Board

    1.25HOURS

    This course is approved by the Louisiana Physical Therapy Board for 1.25 administrative hours.
  • Maryland Board of Physical Therapy Examiners

    1.00HOURS

    This course meets the basic criteria of the Maryland Board of Physical Therapy Examiners for 0.1 CEUs.
  • Maine Physical Therapy Licensing Board

    1.25HOURS

    This activity is approved for 1.25 contact hours.
  • Michigan Board of Physical Therapy

    1.25HOURS

    The Michigan Board of Physical Therapy accepts Continuing Education courses approved by any state physical therapy association. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX. This activity is approved for 1.25 contact hours.
  • Minnesota State Board of Physical Therapy

    1.25HOURS

    This course is approved by the Minnesota Board of Physical Therapy for 1.25 Category 1 credits and offered to PTs and PTAs for CEUs.
  • Missouri Advisory Commission for Professional Physical Therapists

    1.25HOURS

    The Missouri State Board of Registration for the Healing Arts accepts Continuing Education courses sponsored/approved by any state chapter of the American Physical Therapy Association (APTA). Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX. This activity is approved for 1.25 contact hours.
  • Mississippi State Board of Physical Therapy

    1.25HOURS


    The Mississippi State Board of Physical Therapy accepts Continuing Education hours accrued through participation in educational activities approved by any state physical therapy association. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX. This course meets approval under the Mississippi Regulation Part 3103 Rule 5.4 (1) (b).

    This activity is approved for 1.25 contact hours.
  • Montana Board of Physical Therapy Examiners

    1.25HOURS

    The Montana Board of Physical Therapy Examiners accepts Continuing Education courses approved by any state physical therapy association as Category A activities. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX. This activity is approved for 1.25 contact hours.
  • North Carolina Board of Physical Therapy Examiners

    1.25HOURS

    The North Carolina Board of Physical Therapy accepts Continuing Education courses approved by the American Physical Therapy Association and its affiliate components. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX. This activity is approved for 1.25 contact hours.
  • North Dakota Board of Physical Therapy

    1.25HOURS

    The North Dakota Board of Physical Therapy accepts Continuing Education courses sponsored by any state physical therapy association. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX. This activity is approved for 1.25 contact hours.
  • Nebraska Board of Physical Therapy

    1.25HOURS

    The Nebraska State Board of Physical Therapy accepts Continuing Education courses relating to the theory or clinical application of theory pertaining to the practice of physical therapy. This course is approved by the Physical Therapy Board of California and offered to PTs and PTAs for CEUs. This activity is approved for 1.25 contact hours. Disclaimer: It is the learner's responsibility to determine whether or not this course meets the specific renewal requirements established by your licensing board.
  • New Hampshire Board of Physical Therapy

    1.25HOURS

    The New Hampshire Physical Therapy Governing Board recognizes the completion of distance learning courses as maintenance of continuing competence. This activity is approved for 1.25 contact hours.
  • New Jersey State Board of Physical Therapy

    1.25HOURS

    This course was approved by the New Jersey Board of Physical Therapy Examiners. Approval #: 1912-153. This activity is approved for 1.25 contact hours.
  • New Mexico Physical Therapy Board

    1.25HOURS

    The New Mexico Physical Therapy Licensing Board accepts Continuing Education courses approved by any state physical therapy association. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX. This activity is approved for 1.25 contact hours.
  • New York Physical Therapy

    1.25HOURS

    The New York State Education Department's State Board for Physical Therapy has recognized Relias Learning, LLC as an approved provider of physical therapy and physical therapy assistant continuing education. This activity is approved for 1.25 contact hours.
  • Oklahoma Board of Medical Licensure and Supervision

    1.25HOURS

    Oklahoma Physical Therapy Advisory Committee has approved this course under Category B. Approval # 202111423. This activity is approved for 1.25 contact hours.
  • Ohio Physical Therapy Association

    1.25HOURS

    This course is approved by the Ohio Physical Therapy Association, approval number 20S2497. This activity is approved for 1.25 contact hours.
  • Oregon Physical Therapist Licensing Board

    1.25HOURS

    The Oregon Physical Therapist Licensing Board accepts Continuing Education courses approved by any state physical therapy licensing board. This course is approved by the Physical Therapy Board of California and offered to PTs and PTAs for CEUs. This activity is approved for 1.25 contact hours. Disclaimer: It is the learner's responsibility to determine whether or not this course meets the specific renewal requirements established by your licensing board.
  • Pennsylvania State Board of Physical Therapy

    1.25HOURS

    Pennsylvania State Board of Physical Therapy accepts Continuing Education courses approved by the American Physical Therapy Association and its affiliate components. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #2202008TX. This activity is approved for 1.25 contact hours.
  • Georgia State Board of Physical Therapy

    1.25HOURS


    The Georgia State Board of Physical Therapy accepts Continuing Education courses approved by the American Physical Therapy Association and its affiliate components. Relias is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX.

    This activity is approved for 1.25 contact hours.
  • Rhode Island Board of Physical Therapy

    1.25HOURS

    The Rhode Island Board of Physical Therapy accepts Continuing Education courses approved by any state physical therapy association. This activity is approved for 1.25 contact hours.
  • South Carolina Board of Physical Therapy

    1.25HOURS


    The South Carolina Board of Physical Therapy accepts Continuing Education courses approved by any state physical therapy association. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX.

    This activity is approved for 1.25 contact hours.
  • South Dakota State Board of Medical and Osteopathic Examiners

    1.25HOURS

    South Dakota State Board of Medical and Osteopathic Examiners accepts Continuing Education courses approved by the American Physical Therapy Association and its affiliate components. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX. This activity is approved for 1.25 contact hours.
  • Tennessee Board of Physical Therapy (General)

    1.25HOURS


    The Tennessee Board of Physical Therapy accepts Continuing Education courses approved by the American Physical Therapy Association and its affiliate components. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #2202008TX.

    This activity is approved for 1.25 contact hours.
  • Texas Physical Therapy Association

    1.25HOURS

    This activity is provided by The Texas Board of Physical Therapy Examiners Accredited Provider #1902008TX and meets continuing competence requirements for physical therapist and physical therapist assistant licensure renewal in Texas. This course is not approved as meeting the ethics and professional requirements for Texas physical therapists or physical therapist assistants. The assignment of Texas PT CCUs does not imply endorsement of specific course content, products, or clinical procedures by TPTA or TBPTE. This activity is approved for 1.25 contact hours.
  • Utah Board of Physical Therapy

    1.25HOURS

    The Utah Division of Occupational and Professional Licensing accepts Continuing Education courses conducted by commercial continuing education providers. This activity is approved for 1.25 contact hours.
  • Virginia Board of Physical Therapy

    1.25HOURS

    The Virginia Board of Physical Therapy accepts Continuing Education courses approved by any state physical therapy association as Type 1 courses. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX. This activity is approved for 1.25 contact hours.
  • Washington Board of Physical Therapy

    1.25HOURS

    The Washington Board of Physical Therapy accepts Continuing Education courses that are specifically related to the practice of physical therapy, with specified goals and objectives. This course is approved by the Physical Therapy Board of California and offered to PTs and PTAs for CEUs. This activity is approved for 1.25 contact hours. Disclaimer: It is the learner's responsibility to determine whether or not this course meets the specific renewal requirements established by your licensing board.
  • Wisconsin Department of Regulation and Licensing - Physical Therapy

    1.25HOURS

    The Wisconsin Physical Therapy Examining Board accepts Continuing Education courses approved by any state physical therapy association. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX. This activity is approved for 1.25 contact hours.
  • West Virginia Board of Physical Therapy

    1.25HOURS

    This course has been approved by the West Virginia Board of Physical Therapy, approval code REL-F21-042. Approval of this course does not necessarily imply that the WV Board of Physical Therapy supports the views of the presenter or sponsor. This activity is approved for 1.25 contact hours.
  • Wyoming Board of Physical Therapy

    1.25HOURS

    The Wyoming Board of Physical Therapy accepts Continuing Education courses approved by any state physical therapy association. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX. This activity is approved for 1.25 contact hours.
  • Delaware Examining Board of Physical Therapists and Athletic Trainers

    1.25HOURS

    The Delaware Examining Board of Physical Therapists and Athletic Trainers accepts Continuing Education courses approved by any state physical therapy association. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX. This activity is approved for 1.25 contact hours.
  • Alaska Board of Physical Therapy

    1.25HOURS

    The Alaska State Physical Therapy and Occupational Therapy Board accepts Continuing Education courses approved by any state physical therapy association. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX.. This activity is approved for 1.25 contact hours.
  • Alabama State Board of Physical Therapy

    1.25HOURS

    The Alabama Board of Physical Therapy recognizes the completion of distance learning courses as maintenance of continuing competence. This course is approved by the Physical Therapy Board of California and offered to PTs and PTAs for CEUs. This activity is approved for 1.25 contact hours.
  • Alabama State Board of Occupational Therapy

    1.25HOURS


    Alabama State Board Of Occupational Therapy (CEBroker Provider #50-290).

    Occupational Therapists will receive 1.25 contact hours for participating in this course.
  • CA Physical Therapy Board of California

    1.25HOURS

    Relias Learning, LLC is recognized as an approved provider of continuing competency courses by the Physical Therapy Board of California. This course is approved for 1.25 contact hours.
  • Florida Board of Physical Therapy

    1.00HOURS


    The Florida Board of Physical Therapy accepts courses approved by any state chapter of the American Physical Therapy Association. Relias Learning is a Texas CCAP Accredited Provider by the Texas Physical Therapy Association, approval #1902008TX. This activity is approved for 1.0 contact hours.

  • Kansas Board of Healing Arts - Physical Therapy

    1.25HOURS

    This activity meets Kansas State Board of Healing Arts criteria for continuing education and is offered to PTs and PTAs for CEUs. This activity is approved for 1.25 contact hours.
  • Arizona Board of Occupational Therapy Examiners

    1.25HOURS


    Arizona Board Of Occupational Therapy Examiners (CEBroker Provider #50-290).

    Occupational Therapists will receive 1.25 contact hours for participating in this course.
  • Georgia State Board of Occupational Therapy

    1.25HOURS


    Georgia State Board of Occupational Therapy (CEBroker Provider #50-290)

    Occupational Therapists will receive 1.25 contact hours for participating in this course.
  • South Carolina Board of Occupational Therapy

    1.25HOURS


    South Carolina Board Of Occupational Therapy (CEBroker Provider #50-290)

    Occupational Therapists will receive 1.25 contact hours for participating in this course.
  • Louisiana State Board Medical Examiners- Occupational Therapy

    1.25HOURS


    Louisiana State Board of Medical Examiners - Occupational Therapy (CEBroker Provider #50-290)

    Occupational Therapists will receive 1.25 contact hours for participating in this course.
  • Mississippi State Department of Health- Occupational Therapy

    1.25HOURS


    Mississippi State Department of Health- Occupational Therapy (CEBroker Provider #50-290)

    Occupational Therapists will receive 1.25 contact hours for participating in this course.
  • Tennessee Board of Occupational Therapy

    1.25HOURS


    Tennessee Board of Occupational Therapy (CEBroker Provider #50-290)

    Occupational Therapists will receive 1.25 contact hours for participating in this course.


Course Details
  • Course Code:

    REL-RTS-0-DRP
  • Hours:

    1.25
  • Type:

    Online Course
  • Release Date:

    2019-12-01
  • Expiration Date:

    2022-11-30
  • Learning Objectives:

    Describe at least three ways to improve documentation through the use of evidence-based practice, identification of skilled need, and medical necessity.; Explain at least two documentation standards specific to group therapy, co-treatment, confidentiality, and electronic medical records.; Identify five required components of therapy goals.; Illustrate at least five general guidelines for the essential elements of therapy documentation.
  • Outline:

    Section 1: Introduction
    About This Course
    Learning Objectives
    Section 2: General Guidelines
    Requirements
    General Elements
    Evaluation
    Plan of Care
    Evaluation/POC Tips
    Goals
    Deconstructing Goals
    Short and Long-Term Goals
    Writing Goals: SMART Technique
    Daily Notes
    Progress Note
    Discharge Summary
    Discharge Summary Tips
    Review
    Summary
    Section 3: Improving Documentation
    Evidence-Based Practice
    Why Should Therapists Adopt It?
    Documenting Evidence-Based Practice Tips
    Documenting Test Results
    Medical Necessity
    DME Documentation Examples
    Skilled Therapy
    Clinical Reasoning
    Risk Management
    Review
    Summary
    Section 4: Special Considerations
    Group Therapy Documentation
    Co-Treatment
    Co-Treatment Tips
    Confidentiality
    Electronic Documentation
    Review
    Summary
    Section 5: Conclusion
    Summary
    Course Contributor
    Resources
    References
  • Target Audience:

    The target audience for this course is: Entry level Occupational Therapists; Introductory level Physical Therapists; in the following settings: Rehabilitation Settings.
  • Course Delivery Method and Format:

    Asynchronous/Online Distance Learning; please see certificate details for specifics on delivery format.
    Relias has a grievance policy in place to facilitate reports of dissatisfaction. Relias will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias.
    If you require special accommodations to complete this module, please contact Relias Support by completing the web form (https://www.relias.com/help) or by using the chat functionality.
    All courses offered by Relias, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.
    Reference herein to any specific commercial product, process, or service by trade name, trademark, service mark, manufacturer or otherwise does not constitute or imply any endorsement, recommendation, or favoring of, or affiliation with, Relias, LLC.
    All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental.
    To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
  • Accommodations:

    If you require special accommodations to complete this module, please contact Relias Customer Support here.
  • Disclosures:

    Expert Reviewers, Instructors, and Staff Writers disclosures will be listed above after the individuals' biographical paragraph. All other members involved within the planning of this educational activity have declared no conflict of interest exists when planning and developing this course.