Ensure confident clinical decisions and maximum reimbursement in a variety of practice settings such as acute care, outpatient, home care, and nursing homes with the only systematic approach to documentation for rehabilitation professionals! Revised and expanded, this hands-on textbook/workbook provides a unique framework for maintaining evidence of treatment progress and patient outcomes with a clear, logical progression. Extensive examples and exercises in each chapter reinforce concepts and encourage you to apply what you've learned to realistic practice scenarios.
A practical framework shows how to organize and structure PT records, making it easier to document functional outcomes in many practice settings, and is based on the International Classification for Functioning, Disability, and Health (ICF) model - the one adopted by the APTA.
Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, and nursing homes, as well as a separate chapter on documentation in pediatric settings.
Guidelines to systematic documentation describe how to identify, record, measure, and evaluate treatment and therapies - especially important when insurance companies require evidence of functional progress in order to provide reimbursement.
Workbook/textbook format uses examples and exercises in each chapter to reinforce your understanding of concepts.
NEW Standardized Outcome Measures chapter leads to better care and patient management by helping you select the right outcome measures for use in evaluations, re-evaluations, and discharge summaries.
UPDATED content is based on data from current research, federal policies and APTA guidelines, including incorporation of new terminology from the Guide to Physical Therapist 3.0 and ICD-10 coding.
EXPANDED number of case examples covers an even broader range of clinical practice areas.
I: THEORETICAL FOUNDATIONS 1. Disablement Models, ICF Framework and Clinical Decision Making 2. Essentials of Documentation 3. Legal Aspects of Documentation 4. Standardized Outcome Measures NEW! 5. Payment Policy and Coding 6 Electronic Medical Records II: COMPONENTS OF PHYSICAL THERAPY DOCUMENTATION 7. Clinical Decision Making and the Initial Evaluation Format 8. Documenting Reason for Referral: Health Condition and Participation 9. Documenting Activities 10. Documenting Impairments 11. Document the Assessment: Summary and Diagnosis 12. Developing and Documenting Effective Goals 13. Documenting the Plan of Care 14. Documenting Session Notes and Progress Notes Using a Modified SOAP Note Format 15. Special Formats: Documenting Screenings, Discharge Summaries, Letters and Patient Education Materials 16. Documentation in Pediatrics References Appendix A: Guidelines: Physical Therapy Documentation of Patient/Client Management Appendix B: Rehabilitation Abbreviations Appendix C: Answers to Exercises Appendix D: Documentation Review Sample Checklist Appendix E: Strength and Range of Motion Forms