Archives

Writing Meaningful Documentation That Reflects Skilled Therapy

July 31, 2025 by Ashley Zhinin.
This resource helps you document in a way that clearly reflects clinical reasoning, adaptability, and person-centered care, without drowning in jargon. It includes examples, rewrite tips, and reflective tools to support skilled, meaningful therapy notes.
This content is only available to members.

ChatGPT Prompt Structure for SOAP Notes

January 31, 2025 by Ashley Zhinin.
Streamline your documentation process with this guide to using ChatGPT for crafting accurate and efficient SOAP notes. Designed for therapists, this resource provides customizable prompts and tips to help you focus on patient care while maintaining high-quality records.
This content is only available to members.

Medical Abbreviations Shorthand

January 31, 2022 by Megan Berg.
Documentation is rarely anyone’s favorite part of healthcare. This document helps you quickly decipher acronyms used in others documentation and more efficiently write your own documentation. Post it next to your computer as a fast and easy reference or provide it as a reference for student clinicians to help them document more efficiently.
This content is only available to members.

Tips for Effective and Efficient Documentation

January 10, 2022 by Megan Berg.
This resource provides tips to make documentation more efficient but still effective, provides a checklist of what should be included in the documentation of skilled services, and provides a link to access an extensive list of action verbs to use in documentation of rehabilitation services.
This content is only available to members.

Skilled Documentation Dos and Don’ts for OT

January 6, 2022 by Megan Berg.
Skilled documentation is a vital component to ethical standards of care. Proper, accurate documentation can help patients ensure that their services are appropriately covered. This 5-page resource provides information to help clinicians document skilled need appropriately.
This content is only available to members.

Goal Attainment Scale Guide & Worksheet

December 25, 2021 by Megan Berg.
Sometimes formal assessments cannot measure changes, but the Goal Attainment Scale (GAS) is one way to show possible changes after therapy. GAS is a helpful way to identify and work toward achieving goals that are meaningful to the patient. This clinical resource provides directions and examples for using the GAS during the evaluation and therapy.
This content is only available to members.