Documentation for Rehabilitation Professionals

Documentation for Rehabilitation Professionals 

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.


Hours: 1.25


Certificates provided by accrediting body (9 Match)

Louisiana Physical Therapy Board

1.25 HOURS

This course is approved by the Louisiana Physical Therapy Board for 1.25 Administrative hours.

Arkansas State Board of Physical Therapy

1.25 HOURS

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

Florida Board of Physical Therapy

1.25 HOURS

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 1.25 contact hours.

Learners must self-report this completion to CE Broker in order to receive credit from the Florida Board of Physical Therapy.

American Occupational Therapy Association


Relias Learning is an approved provider of continuing education courses by the American Occupational Therapy Association. The assignment of AOTA CEUs does not imply endorsement of specific course content, products, or clinical procedures by AOTA. Category 3. This activity is approved for 1.00 contact hours.

Ohio Physical Therapy Association

1.25 HOURS

This course is approved by the Ohio Physical Therapy Association, approval number 19S2417. This activity is approved for 1.25 contact hours.

Maryland Board of Physical Therapy Examiners


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

West Virginia Board of Physical Therapy

1.25 HOURS

This course has been approved by the West Virginia Board of Physical Therapy, approval code REL-F20-72. 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.

New Jersey State Board of Physical Therapy

1.25 HOURS

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

Minnesota State Board of Physical Therapy

1.25 HOURS

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.

Course Details

Course Code: REL-RTS-0-DRP
Hours: 1.25
Type: Online Course
Content Expiration Date: 11/30/2022
Learning Objectives:
Illustrate at least five general guidelines for the essential elements of therapy documentation.
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.


Section 1: Introduction
About This Course
Learning Objectives
Section 2: General Guidelines
General Elements
Plan of Care
Evaluation/POC Tips
Deconstructing Goals
Short and Long-Term Goals
Writing Goals: SMART Technique
Daily Notes
Progress Note
Discharge Summary
Discharge Summary Tips
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
Section 4: Special Considerations
Group Therapy Documentation
Co-Treatment Tips
Electronic Documentation
Section 5: Conclusion
Course Contributor

Instructor: Ann Elsasser-Root, PT DPT
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. Disclosure: Ann Elsasser-Root, PT DPT has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Target Audience:
The target audience for this course is: entry level Occupational Therapists; Physical Therapists; in the following settings: Rehabilitation Settings.
Relias will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
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 ( 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.
If you require special accommodations to complete this module, please contact Relias Customer Support here.