Supporting Your Skills in Documentation: Screens to Client-Centered Care in Long-Term Care Settings


About the Course  
Providing excellent client centered services depends on documentation that clearly illustrates the medical necessity of the client.  Complete and thorough documentation is the foundation for successful reimbursement of therapy services. If this is achieved, the client, the clinician, and payer will all benefit. This session will address key specific requirements for documentation including screens; evaluation/plan of care; reason for referral; prior level of function; goals; progress reporting and discharge summary. Participants will learn how to evaluate and articulate the medical necessity of their client, illustrate the complexity of their skills to support the necessity of your treatment plans, and recognize through examples what constitutes appropriate documentation.   

Learning Outcomes 
Upon completion of this course, the learner should be able to: 

  • Explain how therapy documentation creates a clinical picture of the client and justifies reimbursement.
  • List specific requirements for documentation including screens; evaluation/plan of care; reason for referral; prior level of function; goals; progress reporting and discharge summary.
  • Outline the complexity of your skills to support the necessity of your treatment plans.
  • Identify through examples what constitutes appropriate documentation. 

About the Author
Neely Sullivan, MPT, CLT-LANA, CDP, has worked with diverse client populations ranging from pediatrics to geriatrics in a variety of clinical settings. These experiences, as well as extensive education in health and wellness topics, have allowed her to develop and implement health and wellness programs for clients and employees. She has served in multiple regional and corporate management roles where she has developed health and wellness program policies. She works closely with multidisciplinary teams to ensure that all individuals have the opportunity to attain their highest level of function and quality of life.  

Ms. Sullivan currently provides educational support to 13,000+ therapists nationwide as an Education Specialist and National Director of Wellness for Select Rehabilitation. She has lectured extensively at the national and state level on the topics related to clinical care, client advocacy, and the role rehabilitation in wellness. She has authored publications focusing on evidence-based practice and clinical care. Ms. Sullivan conducts audits, quality improvement planning, and clinical training for employees and customers monthly. She received her physical therapy degree from Georgia State University and is a member of the APTA (including the sections of Clinical Electrophysiology & Wound Management and Geriatrics). 

How to Receive Credit  

  • Watch the entire video which requires a 2-hour commitment of time. Complete a mandatory test (a passing score of 75% is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention.
  • Provide required personal and payment information.
  • Complete the mandatory course evaluation.
  • Print your Certificate of Completion. 

Resolution of Conflict of Interest*  
Planners, faculty, and others in control of content (either individually or as a group) have no relevant financial relationships with ineligible companies. 

Sponsorship/Commercial Support and Non-Endorsement 
It is the policy of Colibri Healthcare, LLC not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners. 

The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.? 

©2023: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Colibri Healthcare, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers.? 

Accreditations and Approvals 

Colibri Healthcare, LLC is an AOTA Approved Provider of professional development (Provider #9118). The assignment of AOTA CEUs does not imply endorsement of specific course content, products, or clinical procedures by AOTA or indicate AOTA approval of a certification or other professional recognition.