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.
- UNIQUE! Combination textbook/workbook format reinforces your understanding and tests your ability to apply concepts through practice exercises.
- UNIQUE! Systematic approach to documenting functional outcomes provides a practical framework for success in numerous practice settings.
- Case studies show you how to format goals through realistic client examples.
- Practice exercises provide valuable experience applying concepts to common clinical problems.
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
- No. of pages:
- © Saunders 2010
- 17th February 2010
- eBook ISBN:
- eBook ISBN:
Associate Professor, Program in Physical Therapy, New York Medical College, School of Public Health, Valhalla, NY
Associate Professor and Chair, Department of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA