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From The CriticsReviewer: Jean Rogers, MA, PT (Northwestern University Feinberg School of Medicine)
Description: This book addresses several documentation models that demonstrate the decision making process and functional outcomes for a variety of third-party payers. The book also discusses the relationship between patient care, documentation, and quality assurance.
Purpose: The purpose is to educate entry-level practitioners in developing or refining documentation skills using a functional outcome approach to patient evaluation and management. Given the current state of health care reimbursement and reform, the authors' objectives are appropriate and pertinent. The authors meet the objectives in a clear, concise, well-formatted, and well-illustrated text.
Audience: Although the authors state that their intended audience is entry-level practitioners, the appropriate audience includes professionals who wish to improve their patient care management, documentation, and quality assessment. Entry-level practitioners, students, and physical therapists with experience could all benefit from using this book as a self-study program or reference. The authors are credible because of to their combined clinical experience, professional activities, and education.
Features: The black-and-white line drawings and many tables illustrate the model for clinical decision making and relate it to documentation and quality assessment. The references appear current and comprehensive. The table of contents and index both direct the reader appropriately. The appearance of this book makes it easy to read. The case studies and examples cited provide good models for the reader to use. Each chapter has a test and answers to provide feedback for independent learners. The appendix contains further useful documents to support the text.
Assessment: The book is a useful addition to a professional's library. The book will help practitioners or students recognize their roles in the health care system and change how they document care so that documentation reflects decision making and patients' functional outcomes. Applying the principles in this book should enhance documentation and better inform other health care providers and third-party payers about patients' status. If used effectively, this book should help physical therapists effectively document the purpose, goals, and accomplishments of physical therapy management.