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 you’ve learned to realistic practice scenarios.
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Book information

  • Published: February 2010
  • Imprint: SAUNDERS
  • ISBN: 978-1-4557-3627-0


Table of 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 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

References
Appendix A. Guidelines for Physical Therapy Documentation
Appendix B. Rehabilitation Abbreviations
Appendix C. Answers to Exercises
Appendix D. Sample Evaluation Forms