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Progress tracking documentation for

speech, occupational and physical therapists

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Properly constructed documentation supports critical thinking and reasoning by helping students make decisions about the focus and direction of patient care. The formula inherent to student critical thinking and reasoning success is, "if this is true/untrue, then the next step is..." Progress tracking documentation supports the decision-making process using a similar logic. "Treatment activities focused on designated activities. Here are the results of those efforts. Now consider decide what should be done next." Documentation containing this logic steers the course of treatment and becomes a student's training partner.

Students must also learn to tie documented treatment activities to proper coding procedures. In medical settings, codes determine service reimbursement through their description of the clinical experience. There are three types of codes students must understand and integrate with documentation. These include: 1) the International Classification of Disease (ICD) code series, 2) the Current Procedural Terminology (CPT) code series, and 3) the G Code progress tracking series for Medicare Part B services. Coding and documentation requirements hold even the newest graduate accountable for all services delivered to patients.

It is a large leap from that first fall semester of school to a responsible workplace professional. Students and interested professionals should attend the next subscriber seminar titled Professional Skills 101. This presentation shares information about code types and uses, code origins, basic information about linking codes to documentation and about the role of advocacy during the professional career experience. It is an action-packed hour that is free to all students. Join us!

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