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Anatomy of a Rehabilitation Note

Module 12: Documentation, Notes, and Billing Integrity ยท Lesson 1 of 3

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.'

Key takeaways

  • Objective, intervention, response, plan, every time
  • Behavior over interpretation