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Documentation for Rehabilitation
A Guide to Clinical Decision Making in Physical Therapy
- 3rd Edition - November 18, 2015
- Authors: Lori Quinn, James Gordon
- Language: English
- Paperback ISBN:9 7 8 - 0 - 3 2 3 - 3 1 2 3 3 - 2
- eBook ISBN:9 7 8 - 0 - 3 2 3 - 3 1 2 3 4 - 9
Better patient management starts with better documentation! Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy, 3rd Edition shows how to acc… Read more
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Request a sales quoteBetter patient management starts with better documentation! Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy, 3rd Edition shows how to accurately document treatment progress and patient outcomes. Designed for use by rehabilitation professionals, documentation guidelines are easily adaptable to different practice settings and patient populations. Realistic examples and practice exercises reinforce concepts and encourage you to apply what you’ve learned. Written by expert physical therapy educators Lori Quinn and James Gordon, this book will improve your skills in both documentation and clinical reasoning.
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
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
- No. of pages: 288
- Language: English
- Edition: 3
- Published: November 18, 2015
- Imprint: Saunders
- Paperback ISBN: 9780323312332
- eBook ISBN: 9780323312349
LQ
Lori Quinn
Affiliations and expertise
Associate Professor of Movement Science and Kinesiology
Director, Neurorehabilitation Research Lab
Teachers College, Columbia UniversityJG
James Gordon
Affiliations and expertise
Professor and Associate Dean
Division of Biokinesiology and Physical Therapy at the Herman Ostrow School of Dentistry
University of Southern California