Writing What Matters: OT Documentation Across the Continuum of Care

Over the past several years, national medical claim denial rates have steadily increased, rising from 9% in 2016 to 12% in 2023. CMS and national audits consistently show that mosttherapy-related denials stem from insufficient documentation, lack of medical necessity, incomplete care plans, or mismatched coding. A staggering 84% of all denials are considered potentially avoidable, underscoring the need for clear, defensible OT documentation.

This course is a practical, skills-focused session designed to help new occupational therapists build confidence and competence in documentation across Acute Care, Outpatient, Skilled Nursing Facilities, and Home Health. This course breaks down the essential elements of clear, defensible, and audit-ready documentation, emphasizing how to communicate clinical reasoning, justify skilled services, and capture meaningful functional outcomes. Through real-world examples, setting-specific guidance, and actionable strategies, participants will learn how to write notes that support reimbursement, reflect high-quality care, and strengthen their professional practice. Whether you aretransitioning into your first role or seeking to refine yourdocumentation habits, this session provides the tools you need to document with clarity, purpose, and confidence.

Target Audience: Occupational Therapists, Occupational Therapy Assistants

Highlights

• Clearly articulate skilled interventions, justifiable services, and notes that support reimbursement, withstand audits, and protect your professional practice
• Write effective, defensible documentation across multiple settings
• Enhance your communication of clinical reasoning to approach documentation with greater confidence