Documenting Skilled Outpatient Services

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How to Take This Course:

• 1 View Course Worksheet -  View the course worksheet or print it out to review later
• 2 Read the Course Material -  As you read through, mark your answers on the course worksheet to be prepared for the exam
• 3 Take Exam -  You must achieve a score of 70% or higher in order to earn credit for the course.
• You don't need to pay for an exam until AFTER you pass it. If you have any questions or need more information, please click here.

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CEU Course Description

Accurate and thorough documentation is a cornerstone of the occupational therapy profession. It ensures clients receive effective, evidence-based care tailored to their goals, supports reimbursement for services, and promotes clear communication among multidisciplinary healthcare teams. Documentation also helps occupational therapy practitioners remain compliant with the OT Code of Ethics and meet legal and regulatory standards. Despite these advantages, documentation can be time-consuming and challenging—especially across different practice settings, each with its own unique requirements. In outpatient clinics, particularly those not affiliated with larger healthcare systems, there’s often added pressure to produce concise, meaningful documentation that reflects the clinic’s value. Practitioners in these environments must also navigate additional responsibilities, serving not only as care providers but also as communicators and coordinators within the broader healthcare system.

CEU Course Objectives

1. Explain the role of the referring provider in the outpatient occupational therapy treatment process.
2. Describe common CPT codes used by therapists in outpatient treatment settings.
3. Differentiate between reevaluations, recertifications, and progress notes.
4. Outline the basic steps required to amend and maintain medical records.

This course expires on 10/10/2030

Course Date: 2025-09-26

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