Documentation for Rehabilitation
A Guide to Clinical Decision Making
By- Lori Quinn, EdD, PT, Associate Professor, Program in Physical Therapy, New York Medical College, School of Public Health, Valhalla, NY
- James Gordon, EdD, PT, Associate Professor and Chair, Department of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA
- Lori Quinn, EdD, PT, Associate Professor, Program in Physical Therapy, New York Medical College, School of Public Health, Valhalla, NY
- James Gordon, EdD, PT, Associate Professor and Chair, Department of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA
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 youve learned to realistic practice scenarios.
Paperback, 288 Pages
Published: December 2009
Imprint: Saunders
ISBN: 978-1-4160-6221-9
Contents
I. Theoretical Foundations & Documentation Essentials
1. Disablement models, ICF Framework, and Clinical Decision Making
2. Essentials of Documentation
3. Legal Aspects of Documentation - New
4. Clinical Decision Making and the Initial Evaluation FormatII. Components of Physical Therapy Documentation
5. Documenting History: Background Information and Health Condition
6. Documenting History: Participation and Social History
7. Documenting Activities
8. Documenting Impairments in Body Structure and Function
9. Documenting the Assessment: Summary and Diagnosis
10. Documenting Goals
11. Documenting the Plan of Care
12. Daily Notes and Progress Notes using a Modified SOAP FormatIII. Additional Documentation Forms
References
13. Specialized Documentation
14. Documentation in Pediatrics - New
15. Payment Policy and Coding - New
16. Computerized Documentation - New
Appendix A. Guidelines for Physical Therapy Documentation
Appendix B. Rehabilitation Abbreviations
Appendix C. Answers to Exercises
Appendix D. Sample Evaluation Forms
