Documentation: Reporting Skill and Progress

Course overview

Socrates said, The unevaluated life is not worth living. More apropos to our profession, Dr. Loren Fishman said, Unevaluated therapy is not worth giving. So how do we evaluate the therapy we are giving to see if it is really worthwhile? Our documentation of what we do is the best answer. The purpose of this course is to explore multiple aspects of documentation and to suggest ways to better demonstrate skill and progress succinctly. Following the steps we present in this course will help to decrease insurance payment refusals. Third party payers such as CMS and private insurers believe that documentation is a tool that can drive good patient care. Therapists typically see documentation as a necessary evil that takes time away from patient care, but allows them to get paid. In truth, both are correct. Documentation has improved over the years, but capturing the essence of skilled patient assessment and treatment quickly and succinctly is an ongoing challenge. We are doctors now, thus more is expected of our profession than ever before. And more importantly, how do we do it in a way that does not take excessive amounts of time from patient care?