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Clinical documentation words

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Show YOUR Skill in Documentation! 📝✨

Your documentation as a PT or OT should reflect your expertise. Ask yourself:

✔️ Why can’t the patient do this alone?

✔️ Why does this task require a skilled therapist?

✔️ How did I adjust the care to meet the patient’s needs?

Include details like your clinical reasoning, patient presentation, and specific modifications or cues you provided.

It’s all about showing the “why” behind your interventions.

Want more documentation tips?

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