Learn the steps for documenting re-evaluations and review the documentation examples that display what should be included in your patient documentation record at the appropriate intervals through an episode of care.

This training outlines the best practices and most easily implemented steps for writing effective and efficient treatment goals. It demonstrates how to use outcomes assessment tools to show treatment effectiveness and to create patient-centered functional goals.

Here you will learn how to easily document the doctor’s medical decision making and create a written diagnosis from the history, through the examination, to the final diagnosis. You’ll see how to create a proper assessment by using the correct words to reflect the doctor’s medical decision making so that it ties everything together.

Clear examples are given in this module to help providers determine exactly what documentation should be noted for the examination and how to document the rationale for ordering diagnostic tests based on the findings from the history and examination.

The end result of this module should be a clear understanding of the use of OATs in your practice and why they are your friend!

In this section of the module, we introduce examples of a well documented history by highlighting various guidelines and spectacular sample history documentation.