Clinical Documentation - Holistic Health Counselor



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Documentation 209 : Documenting the Assessment: Summary and Diagnosis
1.0

Joanne Brown, MS, OT, CHT

$19.00 USD

Case Studies, Downloadable Course in PDF, Text


More Course Information ▶
  • Explain the role of physical therapists in establishing and documenting a diagnosis
  • Describe the elements of the Assessment section of an evaluation report
  • Appropriately document an Assessment for different case scenarios

Approved States/Territories
  • ALAlabama
  • AKAlaska
  • ABAlberta
  • ASAmerican Samoa
  • AZArizona
  • ARArkansas
  • AEArmed Forces all AE
  • AAArmed Forces Americas
  • APArmed Forces Pacific
  • BCBritish Columbia
  • CACalifornia
  • COColorado
  • CTConnecticut
  • DEDelaware
  • DCDistrict of Columbia
  • FMFederated States of Micronesia
  • FLFlorida
  • GAGeorgia
  • GUGuam
  • HIHawaii
  • IDIdaho
  • ILIllinois
  • INIndiana
  • IAIowa
  • KSKansas
  • KYKentucky
  • LALouisiana
  • MEMaine
  • MBManitoba
  • MHMarshall Islands
  • MDMaryland
  • MAMassachusetts
  • MIMichigan
  • MNMinnesota
  • MSMississippi
  • MOMissouri
  • MTMontana
  • NENebraska
  • NVNevada
  • NBNew Brunswick
  • NHNew Hampshire
  • NJNew Jersey
  • NMNew Mexico
  • NYNew York
  • NLNewfoundland and Labrador
  • NCNorth Carolina
  • NDNorth Dakota
  • MPNorthern Mariana Islands
  • NTNorthwest Territories
  • NSNova Scotia
  • NUNunavut
  • OHOhio
  • OKOklahoma
  • ONOntario
  • OROregon
  • PWPalau
  • PAPennsylvania
  • PEPrince Edward Island
  • PRPuerto Rico
  • QCQuebec
  • RIRhode Island
  • SKSaskatchewan
  • SCSouth Carolina
  • SDSouth Dakota
  • TNTennessee
  • TXTexas
  • UTUtah
  • VTVermont
  • VIVirgin Islands
  • VAVirginia
  • WAWashington
  • WVWest Virginia
  • WIWisconsin
  • WYWyoming
  • YTYukon

Documentation 208 : Documenting Impairments in Body Structure and Function
1.0

Joanne Brown, MS, OT, CHT

$19.00 USD

Case Studies, Downloadable Course in PDF, Text


More Course Information ▶
  • Define impairments in body structure and function
  • Appropriately classify impairments into categories for documentation purposes
  • Document impairments concisely using appropriate terminology and abbreviations
  • Describe documentation of a systems review
  • Describe the seven characteristics of documenting pain

Approved States/Territories
  • ALAlabama
  • AKAlaska
  • ABAlberta
  • ASAmerican Samoa
  • AZArizona
  • ARArkansas
  • AEArmed Forces all AE
  • AAArmed Forces Americas
  • APArmed Forces Pacific
  • BCBritish Columbia
  • CACalifornia
  • COColorado
  • CTConnecticut
  • DEDelaware
  • DCDistrict of Columbia
  • FMFederated States of Micronesia
  • FLFlorida
  • GAGeorgia
  • GUGuam
  • HIHawaii
  • IDIdaho
  • ILIllinois
  • INIndiana
  • IAIowa
  • KSKansas
  • KYKentucky
  • LALouisiana
  • MEMaine
  • MBManitoba
  • MHMarshall Islands
  • MDMaryland
  • MAMassachusetts
  • MIMichigan
  • MNMinnesota
  • MSMississippi
  • MOMissouri
  • MTMontana
  • NENebraska
  • NVNevada
  • NBNew Brunswick
  • NHNew Hampshire
  • NJNew Jersey
  • NMNew Mexico
  • NYNew York
  • NLNewfoundland and Labrador
  • NCNorth Carolina
  • NDNorth Dakota
  • MPNorthern Mariana Islands
  • NTNorthwest Territories
  • NSNova Scotia
  • NUNunavut
  • OHOhio
  • OKOklahoma
  • ONOntario
  • OROregon
  • PWPalau
  • PAPennsylvania
  • PEPrince Edward Island
  • PRPuerto Rico
  • QCQuebec
  • RIRhode Island
  • SKSaskatchewan
  • SCSouth Carolina
  • SDSouth Dakota
  • TNTennessee
  • TXTexas
  • UTUtah
  • VTVermont
  • VIVirgin Islands
  • VAVirginia
  • WAWashington
  • WVWest Virginia
  • WIWisconsin
  • WYWyoming
  • YTYukon

Documentation 207 : Documenting Activities
1.0

Joanne Brown, MS, OT, CHT

$18.00 USD

Case Studies, Downloadable Course in PDF, Text


More Course Information ▶
  • Define activities and function
  • Discuss the factors involved in deciding which activities should be included in physical therapy documentation, including consideration of benchmark activities
  • Identify and classify various aspects of documenting activities
  • Appropriately categorize activities of daily living and instrumental activities of daily living
  • Document activities using a skill-based framework

Approved States/Territories
  • ALAlabama
  • AKAlaska
  • ABAlberta
  • ASAmerican Samoa
  • AZArizona
  • ARArkansas
  • AEArmed Forces all AE
  • AAArmed Forces Americas
  • APArmed Forces Pacific
  • BCBritish Columbia
  • CACalifornia
  • COColorado
  • CTConnecticut
  • DEDelaware
  • DCDistrict of Columbia
  • FMFederated States of Micronesia
  • FLFlorida
  • GAGeorgia
  • GUGuam
  • HIHawaii
  • IDIdaho
  • ILIllinois
  • INIndiana
  • IAIowa
  • KSKansas
  • KYKentucky
  • LALouisiana
  • MEMaine
  • MBManitoba
  • MHMarshall Islands
  • MDMaryland
  • MAMassachusetts
  • MIMichigan
  • MNMinnesota
  • MSMississippi
  • MOMissouri
  • MTMontana
  • NENebraska
  • NVNevada
  • NBNew Brunswick
  • NHNew Hampshire
  • NJNew Jersey
  • NMNew Mexico
  • NYNew York
  • NLNewfoundland and Labrador
  • NCNorth Carolina
  • NDNorth Dakota
  • MPNorthern Mariana Islands
  • NTNorthwest Territories
  • NSNova Scotia
  • NUNunavut
  • OHOhio
  • OKOklahoma
  • ONOntario
  • OROregon
  • PWPalau
  • PAPennsylvania
  • PEPrince Edward Island
  • PRPuerto Rico
  • QCQuebec
  • RIRhode Island
  • SKSaskatchewan
  • SCSouth Carolina
  • SDSouth Dakota
  • TNTennessee
  • TXTexas
  • UTUtah
  • VTVermont
  • VIVirgin Islands
  • VAVirginia
  • WAWashington
  • WVWest Virginia
  • WIWisconsin
  • WYWyoming
  • YTYukon

Documentation 206 : Documenting Reason for Referral: Participation and Social History
1.0

Joanne Brown, MS, OT, CHT

$19.00 USD

Case Studies, Text


More Course Information ▶
  • Describe the components of documenting participation, social history, and general health status
  • Describe the usefulness of standardized outcome measures for documenting participation
  • Describe the process of conducting an interview to obtain information pertaining to level of participation, social history, and general health status
  • Document these components with accuracy and specificity
  • Read and analyze clinical examples emphasized with case examples

Approved States/Territories
  • ALAlabama
  • AKAlaska
  • ABAlberta
  • ASAmerican Samoa
  • AZArizona
  • ARArkansas
  • AEArmed Forces all AE
  • AAArmed Forces Americas
  • APArmed Forces Pacific
  • BCBritish Columbia
  • CACalifornia
  • COColorado
  • CTConnecticut
  • DEDelaware
  • DCDistrict of Columbia
  • FMFederated States of Micronesia
  • FLFlorida
  • GAGeorgia
  • GUGuam
  • HIHawaii
  • IDIdaho
  • ILIllinois
  • INIndiana
  • IAIowa
  • KSKansas
  • KYKentucky
  • LALouisiana
  • MEMaine
  • MBManitoba
  • MHMarshall Islands
  • MDMaryland
  • MAMassachusetts
  • MIMichigan
  • MNMinnesota
  • MSMississippi
  • MOMissouri
  • MTMontana
  • NENebraska
  • NVNevada
  • NBNew Brunswick
  • NHNew Hampshire
  • NJNew Jersey
  • NMNew Mexico
  • NYNew York
  • NLNewfoundland and Labrador
  • NCNorth Carolina
  • NDNorth Dakota
  • MPNorthern Mariana Islands
  • NTNorthwest Territories
  • NSNova Scotia
  • NUNunavut
  • OHOhio
  • OKOklahoma
  • ONOntario
  • OROregon
  • PWPalau
  • PAPennsylvania
  • PEPrince Edward Island
  • PRPuerto Rico
  • QCQuebec
  • RIRhode Island
  • SKSaskatchewan
  • SCSouth Carolina
  • SDSouth Dakota
  • TNTennessee
  • TXTexas
  • UTUtah
  • VTVermont
  • VIVirgin Islands
  • VAVirginia
  • WAWashington
  • WVWest Virginia
  • WIWisconsin
  • WYWyoming
  • YTYukon

Documentation 205 : Documenting Reason for Referral: Health Condition and Participation
1.0

Joanne Brown, MS, OT, CHT

$19.00 USD

Case Studies, Downloadable Course in PDF, Text


More Course Information ▶
  • Identify and classify various aspects of documenting reason for referral, including a patient’s background information, health condition, medications, past medical history, social history/participation, and prior functional status
  • Explain the 3 key elements of describing a patient's current health condition
  • Discuss the implications of direct access for documenting medical diagnoses
  • Describe the process of conducting an interview to obtain information pertaining to gathering history data
  • Appropriately document elements of reason for referral based on case scenarios

Approved States/Territories
  • ALAlabama
  • AKAlaska
  • ABAlberta
  • ASAmerican Samoa
  • AZArizona
  • ARArkansas
  • AEArmed Forces all AE
  • AAArmed Forces Americas
  • APArmed Forces Pacific
  • BCBritish Columbia
  • CACalifornia
  • COColorado
  • CTConnecticut
  • DEDelaware
  • DCDistrict of Columbia
  • FMFederated States of Micronesia
  • FLFlorida
  • GAGeorgia
  • GUGuam
  • HIHawaii
  • IDIdaho
  • ILIllinois
  • INIndiana
  • IAIowa
  • KSKansas
  • KYKentucky
  • LALouisiana
  • MEMaine
  • MBManitoba
  • MHMarshall Islands
  • MDMaryland
  • MAMassachusetts
  • MIMichigan
  • MNMinnesota
  • MSMississippi
  • MOMissouri
  • MTMontana
  • NENebraska
  • NVNevada
  • NBNew Brunswick
  • NHNew Hampshire
  • NJNew Jersey
  • NMNew Mexico
  • NYNew York
  • NLNewfoundland and Labrador
  • NCNorth Carolina
  • NDNorth Dakota
  • MPNorthern Mariana Islands
  • NTNorthwest Territories
  • NSNova Scotia
  • NUNunavut
  • OHOhio
  • OKOklahoma
  • ONOntario
  • OROregon
  • PWPalau
  • PAPennsylvania
  • PEPrince Edward Island
  • PRPuerto Rico
  • QCQuebec
  • RIRhode Island
  • SKSaskatchewan
  • SCSouth Carolina
  • SDSouth Dakota
  • TNTennessee
  • TXTexas
  • UTUtah
  • VTVermont
  • VIVirgin Islands
  • VAVirginia
  • WAWashington
  • WVWest Virginia
  • WIWisconsin
  • WYWyoming
  • YTYukon

Documentation 204 : Documentation in Pediatrics
1.0

Joanne Brown, MS, OT, CHT

$19.00 USD

Downloadable Course in PDF, Text


More Course Information ▶
  • Describe the laws governing documentation in early intervention and school-based settings in the United States
  • Identify commonly used standardized assessments in early intervention and school-based settings
  • Document components of early intervention evaluations and session notes, which are family-centered, child-specific, routines-based, and aligned with the natural environment
  • Document components of school-based evaluations and session notes, which are child-centered and specific to the school setting
  • Create goals for a pediatric client based on best practice standards, including making goals child-centered, context-specific and addressing specific tasks or functional activities

Approved States/Territories
  • ALAlabama
  • AKAlaska
  • ABAlberta
  • ASAmerican Samoa
  • AZArizona
  • ARArkansas
  • AEArmed Forces all AE
  • AAArmed Forces Americas
  • APArmed Forces Pacific
  • BCBritish Columbia
  • CACalifornia
  • COColorado
  • CTConnecticut
  • DEDelaware
  • DCDistrict of Columbia
  • FMFederated States of Micronesia
  • FLFlorida
  • GAGeorgia
  • GUGuam
  • HIHawaii
  • IDIdaho
  • ILIllinois
  • INIndiana
  • IAIowa
  • KSKansas
  • KYKentucky
  • LALouisiana
  • MEMaine
  • MBManitoba
  • MHMarshall Islands
  • MDMaryland
  • MAMassachusetts
  • MIMichigan
  • MNMinnesota
  • MSMississippi
  • MOMissouri
  • MTMontana
  • NENebraska
  • NVNevada
  • NBNew Brunswick
  • NHNew Hampshire
  • NJNew Jersey
  • NMNew Mexico
  • NYNew York
  • NLNewfoundland and Labrador
  • NCNorth Carolina
  • NDNorth Dakota
  • MPNorthern Mariana Islands
  • NTNorthwest Territories
  • NSNova Scotia
  • NUNunavut
  • OHOhio
  • OKOklahoma
  • ONOntario
  • OROregon
  • PWPalau
  • PAPennsylvania
  • PEPrince Edward Island
  • PRPuerto Rico
  • QCQuebec
  • RIRhode Island
  • SKSaskatchewan
  • SCSouth Carolina
  • SDSouth Dakota
  • TNTennessee
  • TXTexas
  • UTUtah
  • VTVermont
  • VIVirgin Islands
  • VAVirginia
  • WAWashington
  • WVWest Virginia
  • WIWisconsin
  • WYWyoming
  • YTYukon

Documentation 203 : Documenting the Plan of Care
1.0

Joanne Brown, MS, OT, CHT

$19.00 USD

Downloadable Course in PDF, Text


More Course Information ▶
  • Identify and describe the components of documentation of the plan of care
  • Appropriately document a plan of care as part of an initial evaluation
  • Discuss the importance of documenting informed consent

Approved States/Territories
  • ALAlabama
  • AKAlaska
  • ABAlberta
  • ASAmerican Samoa
  • AZArizona
  • ARArkansas
  • AEArmed Forces all AE
  • AAArmed Forces Americas
  • APArmed Forces Pacific
  • BCBritish Columbia
  • CACalifornia
  • COColorado
  • CTConnecticut
  • DEDelaware
  • DCDistrict of Columbia
  • FMFederated States of Micronesia
  • FLFlorida
  • GAGeorgia
  • GUGuam
  • HIHawaii
  • IDIdaho
  • ILIllinois
  • INIndiana
  • IAIowa
  • KSKansas
  • KYKentucky
  • LALouisiana
  • MEMaine
  • MBManitoba
  • MHMarshall Islands
  • MDMaryland
  • MAMassachusetts
  • MIMichigan
  • MNMinnesota
  • MSMississippi
  • MOMissouri
  • MTMontana
  • NENebraska
  • NVNevada
  • NBNew Brunswick
  • NHNew Hampshire
  • NJNew Jersey
  • NMNew Mexico
  • NYNew York
  • NLNewfoundland and Labrador
  • NCNorth Carolina
  • NDNorth Dakota
  • MPNorthern Mariana Islands
  • NTNorthwest Territories
  • NSNova Scotia
  • NUNunavut
  • OHOhio
  • OKOklahoma
  • ONOntario
  • OROregon
  • PWPalau
  • PAPennsylvania
  • PEPrince Edward Island
  • PRPuerto Rico
  • QCQuebec
  • RIRhode Island
  • SKSaskatchewan
  • SCSouth Carolina
  • SDSouth Dakota
  • TNTennessee
  • TXTexas
  • UTUtah
  • VTVermont
  • VIVirgin Islands
  • VAVirginia
  • WAWashington
  • WVWest Virginia
  • WIWisconsin
  • WYWyoming
  • YTYukon

Documentation 202 : Developing and Documenting Effective Goals
1.0

Joanne Brown, MS, OT, CHT

$19.00 USD

Downloadable Course in PDF, Text


More Course Information ▶
  • Differentiate between goals and outcomes
  • Describe the important aspects of writing goals at the participation, activity, and impairment levels
  • Distinguish between short-term and long-term goals
  • Describe the essential components of a well-written functional goal Identify poorly written goals and make modifications to goals
  • Appropriately document participation and activity goals for a written report

Approved States/Territories
  • ALAlabama
  • AKAlaska
  • ABAlberta
  • ASAmerican Samoa
  • AZArizona
  • ARArkansas
  • AEArmed Forces all AE
  • AAArmed Forces Americas
  • APArmed Forces Pacific
  • BCBritish Columbia
  • CACalifornia
  • COColorado
  • CTConnecticut
  • DEDelaware
  • DCDistrict of Columbia
  • FMFederated States of Micronesia
  • FLFlorida
  • GAGeorgia
  • GUGuam
  • HIHawaii
  • IDIdaho
  • ILIllinois
  • INIndiana
  • IAIowa
  • KSKansas
  • KYKentucky
  • LALouisiana
  • MEMaine
  • MBManitoba
  • MHMarshall Islands
  • MDMaryland
  • MAMassachusetts
  • MIMichigan
  • MNMinnesota
  • MSMississippi
  • MOMissouri
  • MTMontana
  • NENebraska
  • NVNevada
  • NBNew Brunswick
  • NHNew Hampshire
  • NJNew Jersey
  • NMNew Mexico
  • NYNew York
  • NLNewfoundland and Labrador
  • NCNorth Carolina
  • NDNorth Dakota
  • MPNorthern Mariana Islands
  • NTNorthwest Territories
  • NSNova Scotia
  • NUNunavut
  • OHOhio
  • OKOklahoma
  • ONOntario
  • OROregon
  • PWPalau
  • PAPennsylvania
  • PEPrince Edward Island
  • PRPuerto Rico
  • QCQuebec
  • RIRhode Island
  • SKSaskatchewan
  • SCSouth Carolina
  • SDSouth Dakota
  • TNTennessee
  • TXTexas
  • UTUtah
  • VTVermont
  • VIVirgin Islands
  • VAVirginia
  • WAWashington
  • WVWest Virginia
  • WIWisconsin
  • WYWyoming
  • YTYukon

Documentation 201 : Payment Policy and Coding
1.0

Joanne Brown, MS, OT, CHT

$19.00 USD

Downloadable Course in PDF, Text


More Course Information ▶
  • Provide a brief overview of health care reform and its impact on physical therapy and third-party payers in context of reform environment
  • Describe Medicare settings that outpatient services are provided in, as well as the characteristic policies and key compliance elements required by Medicare and other third-party payers
  • Outline Medicare guidelines for documenting skilled therapy services
  • List the components of documentation for Medicare, including initial evaluations including plan of care, progress notes, session notes, reevaluations, and discharge summaries
  • Understand basics of functional limitation reporting, physician quality reporting system and diagnosis coding and CPT coding for billing and payment purposes
  • Summarize guidelines for CPT coding that may facilitate payment for services and minimize payment delays and denials

Approved States/Territories
  • ALAlabama
  • AKAlaska
  • ABAlberta
  • ASAmerican Samoa
  • AZArizona
  • ARArkansas
  • AEArmed Forces all AE
  • AAArmed Forces Americas
  • APArmed Forces Pacific
  • BCBritish Columbia
  • CACalifornia
  • COColorado
  • CTConnecticut
  • DEDelaware
  • DCDistrict of Columbia
  • FMFederated States of Micronesia
  • FLFlorida
  • GAGeorgia
  • GUGuam
  • HIHawaii
  • IDIdaho
  • ILIllinois
  • INIndiana
  • IAIowa
  • KSKansas
  • KYKentucky
  • LALouisiana
  • MEMaine
  • MBManitoba
  • MHMarshall Islands
  • MDMaryland
  • MAMassachusetts
  • MIMichigan
  • MNMinnesota
  • MSMississippi
  • MOMissouri
  • MTMontana
  • NENebraska
  • NVNevada
  • NBNew Brunswick
  • NHNew Hampshire
  • NJNew Jersey
  • NMNew Mexico
  • NYNew York
  • NLNewfoundland and Labrador
  • NCNorth Carolina
  • NDNorth Dakota
  • MPNorthern Mariana Islands
  • NTNorthwest Territories
  • NSNova Scotia
  • NUNunavut
  • OHOhio
  • OKOklahoma
  • ONOntario
  • OROregon
  • PWPalau
  • PAPennsylvania
  • PEPrince Edward Island
  • PRPuerto Rico
  • QCQuebec
  • RIRhode Island
  • SKSaskatchewan
  • SCSouth Carolina
  • SDSouth Dakota
  • TNTennessee
  • TXTexas
  • UTUtah
  • VTVermont
  • VIVirgin Islands
  • VAVirginia
  • WAWashington
  • WVWest Virginia
  • WIWisconsin
  • WYWyoming
  • YTYukon