Tjane Health portal
Module 12: Documentation, Notes, and Billing Integrity · Lesson 1 of 3
It is 6:15 p.m. and you have nine notes left. Everything you write from here will be read by someone who was not in the room — a reviewer, a supervisor, maybe a court. Speed and defensibility are not opposites; they are the same skill.
Objective, intervention, response, plan.
State the plan objective addressed, the specific intervention (with the teaching method and prompting level), the participant's observable response, and the next step. Include date, time in and out, location, and signature with credential.
Write in behavioral language. 'Participant was resistant' becomes 'Participant declined role-play twice, then completed one rep after we shortened it to two steps.'
Every statement below is labeled so you know what is binding regulation, what is only proposed, what is professional guidance, and what is our house standard.
Notes must be contemporaneous, signed and dated with credentials, and linked to an authorized objective in the current plan.
Telehealth-delivered PRP documentation expectations have been an active area of proposed revision; record modality and participant location until the final language settles.
Objective / Intervention / Response / Plan. Eight minutes. Same day.
Describing what you did without describing what the participant did.
Do this instead — Record the intervention and the participant's observable response to it.
Treating regulation as a filing chore separate from practice.
Do this instead — Let the required elements shape the session itself, so documentation writes itself.
Practical example
Instead of 'met with participant to discuss goals,' write: 'Reviewed the transportation objective; participant identified the #22 route unassisted and named one back-up plan. Verbal prompt needed once. Next session: practice the transfer at Mondawmin.'
Key takeaways
Bring your answers to supervision — the case-study workspace in this module saves written notes to your account.
4 questions drawn from a bank of 7 · 75% to pass · instant feedback on every answer
1. How should you treat this statement? "Notes must be contemporaneous, signed and dated with credentials, and linked to an authorized objective in the current plan."
2. Which additional point does "Anatomy of a Rehabilitation Note" emphasize?
3. A colleague does this: Treating regulation as a filing chore separate from practice. What should they do instead?
4. A colleague does this: Describing what you did without describing what the participant did. What should they do instead?