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Doody's Review ServiceReviewer: 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.