Documentation for Physical Therapist Assistants / Edition 2

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Overview

Finally, a documentation text written specifically for the physical therapist assistant. Documentation for Physical Therapist Assistants contains a historical perspective, information, theories, and guidelines for documenting and writing progress or interim notes in the medical record. It is written in a workbook format and contains review questions and practice exercises after each chapter.

KEY FEATURES:

  • Revised extensively to reflect the language of the APTA Guide to Physical Therapist Practice
  • Focuses on the needs of PTAs, emphasizes the role of the PTA within the PT team, and covers major types of records (SOMR, POMR)
  • Teaches how to make notes (SOAP, narrative, computerized, predesigned)
  • Covers all documentation, including incident reports and phone conversations, and discusses reimbursement and legal issues
  • Includes new sample reports and many new practice exercises (with answers in the back of the book)
  • Contains chapter outlines, objectives, and review questions (with answers in the back of the book)
  • Chapter 7 expanded to differentiate between outcomes and goals and writing treatment session goals

The book contains black-and-white illustrations.

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Editorial Reviews

Jennifer Smith
This introduction to skills used by physical therapist assistants begins by examining the evolution of documentation and the reasons for good quality. The author uses the American Physical Therapy Association's (APTA) Standards of Practice and Guidelines for Documentation as a basis for what should be included and references journals and textbooks by knowledgeable sources in the field. The book ties together the legal and reimbursement aspects while maintaining the primary focus on functional outcomes and quality care. It also includes relevant information on the PT/PTA role delineation and documentation of that interaction. As the title indicates, the book is aimed at PTA students. The author uses established models for documentation by basically following the SOAP format for what type of information belongs in a progress note as well as how to organize it. She compares and contrasts each category in the SOAP format with other common formats, including DEP, PSPG, and FOR. Another strength of the book is the examples of different formats used in specific practice settings, such as the IEP in a school setting, letter format in a private practice setting, or treatment procedures vs. functional skill assessments in outpatient or long-term care settings. The only weakness of the book is that it is somewhat repetitive and, at times, difficult to follow. The summary and review exercises at the end of each chapter allow readers to check their knowledge of main points. Some of the practice exercises, however, require knowledge beyond the introductory level. The book also covers the important issues of confidentiality, informed consent, release of information, telephone orders, refusal oftreatment, and incident reporting. The multiple appendixes include a brief list of abbreviations, tips on documenting modalities, dictation guidelines, answers to review and practice exercises, and a study guide that covers the main points of each chapter in outline form. This is an excellent introduction to the basics of quality documentation for PTA students.
Booknews
A documentation text written specifically for the physical therapist assistant (PTA), showing how to adapt information for different formats and how to use terms and definitions from the APTA . The needs of PTAs and the role of the PTA within the team are highlighted. Covers all documentation, including incident reports and phone conversations, focusing on progress/interim notes, and discusses reimbursement and legal issues. Coverage encompasses both source-oriented medical records and problem- oriented medical records, and formats including SOAP, PSPG, DEP, and FOR. Lukan is affiliated with Lake Superior College. Annotation c. Book News, Inc., Portland, OR (booknews.com)
Doody's Review Service
Reviewer: Jennifer Smith, BS, PT (Owens Community College)
Description: This introduction to skills used by physical therapist assistants begins by examining the evolution of documentation and the reasons for good quality. The author uses the American Physical Therapy Association's (APTA) Standards of Practice and Guidelines for Documentation as a basis for what should be included and references journals and textbooks by knowledgeable sources in the field.
Purpose: The book ties together the legal and reimbursement aspects while maintaining the primary focus on functional outcomes and quality care. It also includes relevant information on the PT/PTA role delineation and documentation of that interaction.
Audience: As the title indicates, the book is aimed at PTA students.
Features: The author uses established models for documentation by basically following the SOAP format for what type of information belongs in a progress note as well as how to organize it. She compares and contrasts each category in the SOAP format with other common formats, including DEP, PSPG, and FOR. Another strength of the book is the examples of different formats used in specific practice settings, such as the IEP in a school setting, letter format in a private practice setting, or treatment procedures vs. functional skill assessments in outpatient or long-term care settings. The only weakness of the book is that it is somewhat repetitive and, at times, difficult to follow. The summary and review exercises at the end of each chapter allow readers to check their knowledge of main points. Some of the practice exercises, however, require knowledge beyond the introductory level. The book also covers the important issues of confidentiality, informed consent, release of information, telephone orders, refusal of treatment, and incident reporting. The multiple appendixes include a brief list of abbreviations, tips on documenting modalities, dictation guidelines, answers to review and practice exercises, and a study guide that covers the main points of each chapter in outline form.
Assessment: This is an excellent introduction to the basics of quality documentation for PTA students.

3 Stars from Doody
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Product Details

  • ISBN-13: 9780803608375
  • Publisher: F. A. Davis Company
  • Publication date: 1/28/2001
  • Edition description: Older Edition
  • Edition number: 2
  • Pages: 208
  • Product dimensions: 8.32 (w) x 10.96 (h) x 0.45 (d)

Table of Contents

Pt. 1 Why Document? 1
Ch. 1 Introduction to Documentation 3
Ch. 2 Documentation Content 13
Ch. 3 Organization and Presentation of the Content 27
Pt. 2 How to Document 49
Ch. 4 Writing the Content: Guidelines 51
Ch. 5 Writing the Content: Subjective Data 61
Ch. 6 Writing the Content: Objective Data 75
Ch. 7 Writing the Content: Diagnoses, Functional Outcomes, Goals, and Treatment Effectiveness 95
Ch. 8 Writing the Content: Intervention Plan 113
Ch. 9 Other Documentation Responsibilities 119
Ch. 10 Documentation Summary: Study Guide 131
Bibliography 157
Glossary 158
App. A: Abbreviations 162
App. B: Documenting Interventions 165
App. C: Dictation Guidelines 166
App. D: Answers to Review Exercises 167
App. E: Answers to Practice Exercises 174
App. F: Guidelines for Physical Therapy Documentation 195
Index 201
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