Documentation for Rehabilitation - 3rd Edition - ISBN: 9780323312332, 9780323312349

Documentation for Rehabilitation

3rd Edition

A Guide to Clinical Decision Making in Physical Therapy

Authors: Lori Quinn James Gordon
eBook ISBN: 9780323312349
eBook ISBN: 9780323312370
Paperback ISBN: 9780323312332
Imprint: Saunders
Published Date: 11th December 2015
Page Count: 288

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Better 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.

Key Features

  • A practical framework shows how to organize and structure PT records, making it easier to document functional outcomes in many practice settings, and is based on the International Classification for Functioning, Disability, and Health (ICF) model — the one adopted by the APTA.
  • Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, and nursing homes, as well as a separate chapter on documentation in pediatric settings.
  • Guidelines to systematic documentation describe how to identify, record, measure, and evaluate treatment and therapies — especially important when insurance companies require evidence of functional progress in order to provide reimbursement.
  • Workbook/textbook format uses examples and exercises in each chapter to reinforce your understanding of concepts.

Table of Contents

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
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  
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:
© Saunders 2016
11th December 2015
eBook ISBN:
eBook ISBN:
Paperback ISBN:

About the Authors

Lori Quinn

Affiliations and Expertise

Associate Professor of Movement Science and Kinesiology Director, Neurorehabilitation Research Lab Teachers College, Columbia University

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