Documentation for Rehabilitation book cover

Documentation for Rehabilitation

A Guide to Clinical Decision Making

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.

Book, 304 Pages

Published: February 2010

Imprint: Saunders

ISBN: 978-1-4557-3627-0


  • 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 Format

    II. 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 Format

    III. Additional Documentation Forms
    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


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