Defensible Documentation:

The Dos and The Don’ts


The healthcare landscape is ever changing, and the last 2 years have been no exception. Therapists are now, more than ever, responsible for justifying our necessity in the care of our patients. We know that we are necessary, but often have a difficult time communicating that outside of our immediate circle of influence. In this course, we will discuss defensible documentation, something that most therapists consider a necessary evil, but is absolutely essential to justification of our role in the healthcare team and to reimbursement. We will explore the reasons we document, the mandatory components of documentation, the inevitable pitfalls to successful documentation, and ways to ensure defensible documentation. As we move forward in a healthcare system that is ever evolving, our efforts to shape the landscape around us begin with our ability to document effectively. In the state of Tennessee in February, 2020, a provider of skilled nursing services entered an agreement to repay $9.5 million of Medicare funds because their services were determined to be unreasonable, unnecessary and unskilled. As a business owner who bills Medicare and other commercial payors, this frightens and saddens me. As a therapist, I know that what I am doing is reasonable, necessary and skilled, but I must be able to communicate that to others. Documentation is our main means of communicating!

Introduction and definitions, effective communication of reasonable and medically necessary services, effective communication of skilled services from evaluation through discharge –1 hour

Avoiding pitfalls to effective communication through defensible documentation, developing methods and practical solutions to document effectively and efficiently – 1 hour

Real world examples of defensible documentation, and real world examples (unfortunately) of documentation that is not defensible, discussion period  – 1 hour

Upon completion of this course participants will be able to:

  1. Define skilled services, medically necessary and reasonable services
  2. Implement defensible documentation in the clinical setting that communicates skilled, medically reasonable and necessary care
  3. Compile tools necessary to make documentation more effective and efficient
  4. Identify documentation that is defensible versus documentation that is not defensible

Instructional Methods of this RECORDED WEBINAR

A recorded webinar is a video course that was recorded from a previously given LIVE Webinar. It is delivered over the Internet to your computer. You will be able to see, hear and listen to the course presenter.  This type of webinar will utilize previously recoreded instruction, demonstrative videos, power point slides and more. You will not have the opportunity to ask questions during the seminar as it is recorded. A comprehensive handout will be made available to you after you register for the webinar. The written content used in the presentation will also be made available to you for your personal use (Power Point Slides, Reference Materials etc.).

Financial Disclosure: The course speaker is a lecturer for GREAT Seminars. He/she receives payment from GREAT Seminars for the presentation of this course.

Nonfinancial Disclosure: No relevant nonfinancial relationship exists.

Content Disclosure: This course does not focus solely on any specific product or service.

EDUCATIONAL CREDIT: A certificate of attendance for 3 contact hours of educational activity (3 CEUs or 3.0 CEUs depending on how your Practice Act determines CEUs in your state) will be awarded to registrants upon completion of the Recorded Webinar.

OCCUPATIONAL THERAPY: This course is not approved by the American Occupational Therapy Association (AOTA).  This course is approved by the Florida Board of Occupational Therapy for 3 contact hours.

PHYSICAL THERAPY: 

This course is approved by APTA Arkansas for 3 contact hours. Approval # APTA-AR 2722. No expiration.

This course is approved for PTs and PTAs in California for 3 contact hours by GREAT Seminars and Books, a Continuing Competency Approval Agency of the Physical Therapy Board of California. #GSB00081.

Great Seminars is a licensed Physical Therapy CE Sponsor with the State of Illinois Department of Financial and Professional Regulations, Division of Professional Regulation. License # 216000032.  Exp. 9/30/26.

This course is approved by the Maryland Board of Physical Therapy Examiners for 3 CE Hours. Approval #2025-179. Exp. 2/6/29.

Great Seminars is an approved provider of continuing education with the New Mexico Board of Physical Therapy. Exp. 12/31/26.

Great Seminars and Books is approved as a sponsor of continuing education for PTs and PTAs through the New York State Education Department, Office of the Professions. Exp. 8/31/27.

This course is approved by the Oklahoma Board of Medical Licensure and Supervision – Physical Therapy Board for 3 contact hours.

This activity is provided by the Texas Board of Physical Therapy Examiners Accredited Provider 2805011TX & meets continuing competence requirements for physical therapist and physical therapist assistant licensure renewal in Texas. Exp. 5/31/28.

Our courses also meet the guidelines for approval in Alabama, Alaska, Arizona, Connecticut, Washington DC, Delaware, Georgia, Hawaii, Idaho, Iowa, Indiana, Kansas, Kentucky, Massachusetts, Michigan, Missouri, Mississippi, Montana, Nebraska, New Hampshire, North Carolina, North Dakota, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Vermont, Virginia, Washington, Wisconsin, Wyoming.

Please verify the individual licensing board’s rules regarding allowable hours for recorded/online education.

This course is not approved by ASHA or Board of Certification. Any reference to or mention of state rules or regulations concerning continuing education requirements are true and accurate to the best of our knowledge at the time of print. If you have questions, please contact your board or regulating body.

If you do not see your state listed here, please email us at greatseminars@aol.com or give us a call at 877 794 7328.

3 Contact Hours - $99.00



Your Instructor

Kathy Fagan, PT, MPT, COFS, FSOAE, GTCCS, EOLD, GCS



Unlimited access: Once you have purchased a course, you have unlimited access. You may stop and start and rewind as often as you wish. The course will remain in your cart and you are free to review the content at any time.
Accessing this course: Click on “Enroll Now.” Once you have submitted the registration information, click “Order Now”. You will then see a “Thank You” message. You will be emailed a username, password and information on how to log in to our learning management system (LMS).
Educational Level:Intermediate
Course Format: Online video course
Target Audience: Physical Therapist, Physical Therapist Assistant, Occupational Therapist, Occupational Therapist Assistant.