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.

The key to indisputable documentation is to demonstrate your skill, record progress, and show medical necessity. Carole Lewis shows you how to do all 3 without taking excessive amounts of time from patient care.

She uses real patient examples, hilarious interactive vignettes, shortcuts, and skilled terminology handouts and flow sheets to help clinicians become more efficient and effective documenters.

Managed care does not equal patient denials. But if your documentation has resulted in denials, Dr. Lewis explains how to fight them effectively.

Phrases like “continue as above” or “patient tolerated treatment well” are not just a waste of space. They’re red flags. Learn the correct and easy phrases that demonstrate your skill, record progress, and show medical necessity without increasing your documentation time. Correct phrases will save you hours of time and help your patients to get the care they need because your notes justify it.

Dr. Lewis is clear and concise, but she also uses humor to get her points across.  The segment featuring a mock Self-help Group for Poor Documenters is hilarious.

Stop taking courses that “should” on you and take this one that enables you to create better initial, progress, daily and discharge notes in a practical fashion.

The handouts will make your documentation incredibly easy and indisputable. The handouts include:

• Documentation skilled terminology sheet
• Functional test norms
• 3 case studies
• Examples of initial evals and re-evals
• Daily notes
• Discharge summaries
• Home exercise programs
• Plan of care and progress flow sheet
• Recommended documentation equipment list

“I can now reflect a higher level of care in my documentation.”

“I’m going to share with others in my facility how to incorporate skilled terminology more concisely”

“Loved both of the case examples….very helpful in confirming how much can be done for both high and lower functioning patients.”

“The video of Dr. Lewis performing the initial evaluations with the feedback afterwards- excellent! The treatment plan and how she carried out that plan from day one & as the patient progressed was great. Loved the ongoing dialog explaining what she was doing & why. Appreciated her positive demeanor.”