Documentation for Physical Therapist Practice: A Clinical Decision Making Approach provides the framework for successful documentation. It is synchronous with Medicare standards as well as the American Physical Therapy Association's recommendations for defensible documentation. It identifies documentation basics which can be readily applied to a broad spectrum of documentation formats including paper-based and electronic systems. This key resource utilizes a practical clinical decision making approach and applies this framework to all aspects of documentation. This text emphasizes how the common and standard language of the Guide to Physical Therapist Practice and the International Classification of Functioning, Disability, and Health (ICF) model can be integrated with a physical therapist's clinical reasoning process and a physical therapist assistant's skill set to produce successful documentation.
Includes content on documentation formations: Initial Evaluations, Re-examination Notes, Daily Notes, Conclusion of the Episode of Care Summaries, Home Exercise Program
Reviews all the important issues related to style, types of documentation, and utilization of documentation
Covers documentation relevant in different settings (inpatient, home health, skilled nursing facility, outpatient)
Helps students learn how to report findings and demonstrate an appropriate interpretation of results
Includes up-to-date information in line with APTA Guidelines for Defensible Documentation, World Health Organization, International Classification of Functioning Disability and Health Mode, and Medicare
Reviews electronic documentation, ICD-9, ICD-10, and CPT codes
Includes important chapters on Interprofessional Communication, Legal Aspects, Principles of Measurement