The rules for documentation in the SNF are different for Medicare Part A and Part B.

Do you know what is required and when?

Gain a clear understanding of how to document for successful outcomes!

Our evaluation, progress report, daily note and multiple other templates give you a head start!


This course is divided into 2 parts to help the learner understand the material.

Part 1 focuses on the rules from the CMS manuals, including which documents are required and when. Simple outlines and handouts answer these questions for both Medicare Part A and Part B in the SNF, and provide the source from the Medicare Manual to back it up:

  • Is a MD order required for evaluation?
  • Is a MD order required for treatment?
  • Does the MD need to sign the evaluation?
  • Are clarification orders required?
  • Is a Plan of Care required? If so, what does it need to contain?
  • What does the Initial Evaluation need to contain?
  • Is a Progress Note or Progress Report required?
  • Is a Daily Treatment Note required? (you may be surprised on this one!)
  • What are the unique rules about Discharge Summaries?

Part 2 focuses on the content for each document, providing a “how-to” approach with examples and templates for each document. The required content for each document is reviewed to ensure documentation supports skilled care. Strategies and samples for each type of note are included.

  • Course Outline:
    • Documentation Rules: Who, What, When, Where and Why
      • Therapy required documents: What are they? When are they required and Who can create them?
      • Each component rules is looked at under Part A vs Part B vs Practice Act Rules
      • Who can do what for each document? Assistants and Students
    • Documentation Content: The How To for PT, OT, SLP
      • Content requirements
      • Supporting skilled care
      • Documentation strategies


  • Includes:
    • Video Presentation
    • Presentation Handouts
    • Supplemental Materials Including:
      • Fact Sheet: Requirements for Med A vs Med B
      • PT, OT and SLP Evaluation Templates (Medicare Compliant)
      • PT, OT and SLP Progress Report Templates
      • PT, OT and SLP Daily Treatment Encounter Note Templates
      • Objective Tests and Measure Sample Templates
        • Tinetti Test
        • Berg Balance Test
        • Functional Reach Test


Duration: 3 Contact Hours | .30 CEU’s

Level: (x) Entry Level   ( x) Intermediate (x )Advanced

This course is appropriate for Rehab Directors, PT, PTA, OT, COTA, SLP and MDS Coordinators

Type: Audio and Video

Participant has the ability to remotely interact with presenter to ask questions.


Instructor Credentials: Dolores Montero, PT, DPT, RAC-CT, RAC-CTA (Click for Bio)


1 Course totaling 3 Contact Hours of Continuing Education Credit *

Presentation slides, written materials and valuable downloads/links listed above

Access to Course Instructor for questions about the material.

Certificate of Completion

*Participant is responsible for determining if course meets state requirements for CE credit. Contact us prior to purchase if you need assistance determining state requirements for your discipline.


  • Facility Members: FREE (Contact us for link)
  • Individual Members: $99
  • Individual Members get 1 free course per year (email us if you want this as your free one)
  • This Course is included in our Rehab Manager Certification Program

*Log in with your Individual Membership to Access the purchase link above*

Learn more about our Membership Levels HERE

We are confident you will find value in this course.

If you are not completely satisfied, we will refund your purchase.

Questions? Contact Us