Effective Therapy Documentation is a new 3-hour online continuing education (CE/CEU) course that explores components for maintaining well-written and comprehensive documentation notes.
While patient care is the heart of a rehabilitation therapist’s work, medical documentation is its necessary counterpart. Effective therapy documentation is crucial for reimbursement, accountability, communication (both within and outside of your profession), and progress tracking. However, it can be overwhelming to strike a balance between writing concise notes and offering necessary detail, making this an area many therapists find difficult. Many occupational therapy (OT) and speech-language pathology (SLP) programs do not offer hands-on training for documentation, and it can be frustrating to get used to this writing style while fulfilling other job requirements. This course was created to support practitioners with practical strategies and examples to aid them with documentation.
Sections 1 and 2 discuss the purpose of therapy documentation, reminding us that notes and reports may be used beyond the medical industry, as they may be reviewed by state agencies, attorneys, insurance companies, and other payers, as well as the patients themselves. After reviewing the ways in which these outside agencies use therapy notes, the author moves on to discuss the difference between electronic medical records (EMRs) and electronic health records (EHRs,) and the importance of maintaining and safeguarding all records. This is followed by a look at the federal legislation that guides documentation, such as HIPAA and the HITECH Act.
Section 3 describes how medical necessity impacts therapy documentation and outlines the criteria that must be met before a patient can receive treatment. The author breaks down the guidelines for receiving home health care, inpatient care, acute care, and mental health care, as well as care in skilled nursing facilities and educational settings.
Section 4 offers detailed information on the common terminology and abbreviations used in medical documentation. These pages can be printed for later reference. Section 5 focuses on the different documentation styles, the settings in which each style is appropriate, and the components for writing measurable and appropriate therapy goals. Section 6 ends the course with a breakdown of best practices to follow when writing any type of therapy documentation.
Reflection questions and brief “discussion” points, as well as key words, are offered as opportunities to consider and consolidate the information presented in each section. Please note that while this course offers a scoping view of documentation for therapy professionals, none of this information is guaranteed to prevent billing and/or documentation issues in your practice.
Outline
- Introduction
- Section 1: Purpose of Therapy Documentation
- Section 2: Federal Legislation & Therapy Documentation
- Section 3: Medical Necessity & Its Impact on Therapy Documentation
- Section 4: Common Terminology & Universal Abbreviations in Therapy Documentation
- Section 5: Documentation Styles and Examples
- Section 6: Documentation Best Practices
- Conclusion
Course #31-66 | 2026 | 32 pages | 15 posttest questions | Mobile-Friendly
Click here to learn how to improve your therapy documentation.
About the Author
Brittany Ferri, PhD, OTR/L is an occupational therapist and the owner of Simplicity of Health, LLC, a consulting and health writing business. She has 10 years of experience working in mental health and pediatrics with specialties in documentation, medical writing, and telehealth. Brittany has published 4 books, written over 350 articles, and created more than 50 continuing education courses on various health topics.
Course Directions
This course is text-based (reading), and the CE test is open-book (you can print the test to mark your answers on it while reading the course materials). Successful completion of this course involves passing an online test (80% required, three chances to take) and we ask that you also complete a brief course evaluation. Contact us with any questions – we are here to help!
CE Information
Occupational Therapy
Professional Development Resources is an AOTA Approved Provider of professional development. Course approval ID #16109. This distance learning-independent course is offered at 0.3 CEUs [introductory level, professional issues]. The assignment of AOTA CEUs does not imply endorsement of specific course content, products, or clinical procedures by AOTA.
Professional Development Resources is also approved by the Florida Board of Occupational Therapy and is CE Broker compliant (#50-1635 – completions are reported next business day, currently reporting for 50+ boards).
Speech-Language Pathology
Introductory Level | 0.3 ASHA CEUs | ASHA credit is available until 4/30/2031. ASHA CEUs are awarded by the ASHA CE Registry upon receipt of the monthly completion report from the ASHA Approved CE Provider (#AAUM5197). Please note that the date that appears on ASHA transcripts is the last day of the month in which the course was completed.
Professional Development Resources is also approved by the Florida Board of Speech-Language Pathology and Audiology, the Ohio Board of Speech-Language Pathology and Audiology, the South Carolina Board of Examiners in Speech-Language Pathology and Audiology, and is CE Broker compliant (#50-1635 – completions are reported next business day, currently reporting for 50+ boards).
ASHA CE Provider approval and use of the Brand Block does not imply endorsement of course content, specific products, or clinical procedures.
Professional Development Resources, a small Florida nonprofit educational corporation 501(c)(3) organized in 1992, is approved by the American Psychological Association (APA) to sponsor continuing education for psychologists. Professional Development Resources maintains responsibility for all programs and content. Professional Development Resources is also approved by the National Board of Certified Counselors (NBCC ACEP #5590); the Association of Social Work Boards (ASWB #1046, ACE Program); the Continuing Education Board of the American Speech-Language-Hearing Association (ASHA #AAUM); the American Occupational Therapy Association (AOTA #3159); the Commission on Dietetic Registration (CDR Prior Approval Program); the Florida Board of Clinical Social Work, Marriage & Family Therapy, and Mental Health Counseling, Board of Psychology, Office of School Psychology, Board of Speech-Language Pathology & Audiology, Board of Occupational Therapy, and Dietetics and Nutrition Practice Council; the New York State Education Department’s State Board for Psychology as an approved provider of continuing education for licensed psychologists (#PSY-0145), State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors (#MHC-0135) and marriage and family therapists (#MFT-0100), and the State Board for Social Workers as an approved provider of continuing education for licensed social workers (#SW-0664); the South Carolina Board of Professional Counselors and Marriage & Family Therapists (#193); the Texas Board of Examiners of Marriage and Family Therapists (#114) and State Board of Social Worker Examiners (#5678); and is CE Broker compliant (#50-1635 – completions are reported next business day, currently reporting for 50+ boards). Learn more about us.
Target Audience: Psychologists, School Psychologists, Counselors, Social Workers, Marriage & Family Therapists (MFTs), Speech-Language Pathologists (SLPs), Occupational Therapists (OTs), Registered Dietitian Nutritionists (RDNs), and Teachers
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