Documentation for Rehabilitation: A Guide to Clinical Decision Making / Edition 2

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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.

• Four NEW chapters address additional aspects of documentation that rehabilitation professionals will encounter in practice:

• Legal aspects of documentation
• Documentation in pediatrics
• Payment policy and coding
• Computerized documentation

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Product Details

  • ISBN-13: 9781416062219
  • Publisher: Elsevier Health Sciences
  • Publication date: 1/1/2010
  • Edition description: New Edition
  • Edition number: 2
  • Pages: 288
  • Sales rank: 249,914
  • Product dimensions: 8.40 (w) x 10.80 (h) x 0.60 (d)

Table of 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

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