Documentation: Reporting Skill and Progress Part 1

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Video Runtime: 63 Minutes; Learning Assessment Time: 31 Minutes

This course is Part 1 in a five-part series on documentation with a focus on reporting skill and progress and how you can get the best out of your documentation. The purpose of this course is to explore multiple aspects of documentation and suggest ways to better demonstrate skill and progress succinctly.

This is course 1 in a series of five. Below are all the courses in the series.

Meet your instructor

Carole B. Lewis

Dr. Lewis has worked in home health, long-term care, acute hospitals, rehabilitation departments and outpatient clinics. She started a private practice in Washington, D.C. in 1981 and continues to work as a clinician. Dr. Lewis received her two master’s degrees in health care management and gerontology from the University of…

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Chapters & learning objectives

1. Introduction to Documentation

This chapter introduces electronic documentation and how therapists can learn to make their documentation better in a way that works for them. We will discuss the benefit of using evidence and norms in notes to show skill. A skit demonstrating how to improve documentation of the skill you've added to your patient's care is included.

2. Discussion With Alice Bell

This chapter features a discussion with Doctor Alice Bell, who talks about the importance of documentation in treatment as well as how a therapist's value is demonstrated through documentation.

3. Documenting the Initial Evaluation

This chapter reviews three initial evaluation note examples with recommended improvements for writing more detailed documentation of patient care.

4. Documenting Progress in Notes

This chapter discusses documenting progress in your notes. A skit demonstrating how to improve documentation of the progress your patient demonstrates during your sessions is included.

More courses in this series