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A Guide to Clinical Decision Making
To order this title, and for more information, click here
Second Edition
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
Description
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.
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
| Bibliographic details |
Paperback, 288 pages, publication date: DEC-2009
ISBN-13: 978-1-4160-6221-9
ISBN-10: 1-4160-6221-1
Imprint: SAUNDERS
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999/999
Last update: 10 Nov 2009
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