Physical Therapy Documentation: From Examinations to Outcome / Edition 2

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Overview

Complete and accurate documentation is one of the most essential skills for a physical therapist to develop and use effectively. Necessary for both new and experienced practitioners, the new and updated Second Edition of Physical Therapy Documentation: From Examination to Outcome will teach and explain physical therapy documentation from A to Z. Physical Therapy Documentation, Second Edition provides individuals with the knowledge and skills for documenting physical therapy services. The text begins with several chapters of background information that give the rationale for quality documentation. Physical Therapy Documentation, Second Edition provides the physical therapist's ethical responsibility for quality record keeping. The mechanics of note writing are delivered in a manner friendly to those who are learning the basic elements of documentation. Mia Erickson, Ralph Utzman, and Rebecca McKnight also include chapters on professional responsibilities and reimbursement issues commonly associated with documentation that are important to physical therapists. Each chapter includes examples and opportunities for practice covering a variety of physical therapy patients and settings. Features in the Second Edition:
• Multiple sections covering electronic documentation, including the positive and negative aspects and common pitfalls.
• Use of research evidence on integrating and documenting tests and measures is provided in the mechanics of note writing.
• Multiple templates for documenting initial notes, interim notes, and discharge summaries are given but deviation from these templates, such as during use of the electronic record, are also discussed.
• Ethical and regulatory issues related to documentation of physical therapy care.
• Increased emphasis on documenting contemporary concepts such as skilled services and medical necessity. In keeping with the familiarity of the basic SOAP structure, Physical Therapy Documentation, Sec

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Editorial Reviews

From the Publisher

“This Second Edition includes an abundant amount of solid, up-to-date information to help aspiring physical therapists or new clinicians write superior S.O.A.P notes, covering various types of notes in different settings.  A bonus for clinicians is a chapter covering documentation and reimbursement including insurance basics, Medicare plans, basic coding, and proper billing using CMS time coding.  New therapists will find this invaluable."

- Jennifer C. Hoffman, PT, DPT, OCS, Doody’s Review Service

Doody's Review Service
Reviewer: Jennifer C. Hoffman, PT, DPT, OCS (Private Practice)
Description: This update of a 2008 book thoroughly describes how to write various types of physical therapy documentation for the medical record in diverse clinical settings.
Purpose: The purpose is to provide a reference on all aspects of documentation, from taking phone orders in the outpatient setting to writing discharge reports in a skilled nursing facility. The book uses the S.O.A.P. note format and emphasizes documentation of the skilled care services that physical therapists provide in order to maximize reimbursement for therapy services.
Audience: This book is most suitable as a guide to proper documentation for physical therapy students. Experienced therapists will already be well versed in the documentation of various types of notes.
Features: "This update briefly covers needed documentation for CMS in the wake of the Affordable Care Act. Its breakdown of the basic S.O.A.P. note format into chapters that discuss each aspect of note writing is useful to students. Flow charts also help clinicians to include all pertinent information in written notes. The book emphasizes the use of outcome measures for goal writing, but does not focus on the components needed to write proper goals. This is evidenced by the lack of emphasis on using functional measures, in addition to outcome measures, in writing long-term goals to develop a more direct treatment plan. "
Assessment: This second edition includes an abundant amount of solid, up-to-date information to help aspiring physical therapists or new clinicians write superior S.O.A.P. notes, covering various types of notes in different settings. A bonus for clinicians is a chapter covering documentation and reimbursement including insurance basics, Medicare plans, basic coding, and proper billing using CMS time coding. New therapists will find this invaluable.
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Product Details

  • ISBN-13: 9781617112515
  • Publisher: Slack, Inc.
  • Publication date: 10/1/2013
  • Edition description: New Edition
  • Edition number: 2
  • Pages: 192
  • Sales rank: 265,306
  • Product dimensions: 8.40 (w) x 10.90 (h) x 0.50 (d)

Meet the Author

Mia L. Erickson, PT, EdD, CHT, ATC is an associate professor and co-Academic Coordinator of Clinical Education in the Division of Physical Therapy at the West Virginia University School of Medicine. Mia holds a Bachelor’s Degree from West Virginia University in Secondary Education and a Master's of Science Degree in Physical Therapy from the University of Indianapolis. She earned her doctor of education degree with emphasis in Curriculum and Instruction from West Virginia University. Her clinical practice is in the area of hand and upper extremity rehabilitation.

Ralph R. Utzman, PT, MPH, PhD is an associate professor and co-Academic Coordinator of Clinical Education in the Division of Physical Therapy at the West Virginia University School of Medicine. He holds a Bachelor's Degree in Physical Therapy and a master’s degree in Public Health from West Virginia University, and a PhD in Health Related Sciences from the MCV Campus of Virginia Commonwealth University. His current clinical practice focuses on patients with vestibular disorders and Parkinson's disease. He teaches in the areas of professional practice roles, practice administration, and clinical skills.

Rebecca McKnight, PT, MS received her Bachelor's of Science degree in Physical Therapy from St. Louis University in 1992 and her post-professional Master's of Science degree from Rocky Mountain University of Health Professions in 1999. Rebecca taught  in the Physical Therapist Assistant Program at Ozarks Technical Community College in Springfield, MO from 1997 to 2011. Nine of those years she served as Program Director. Currently Rebecca provides consultation related to curriculum design, development, and assessment through her company Reach Consulting. Rebecca is an active member of the American Physical Therapy Association, primarily within the Education Section.

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Table of Contents


Acknowledgments
About the Authors
Preface

Chapter 1: Overview of Disablement
Mia L. Erickson, PT, EdD, CHT, ATC
Chapter 2: Reasons for Documenting in Physical Therapy
Mia L. Erickson, PT, EdD, CHT, ATC
Chapter 3: Ethical and Regulatory Issues in Physical Therapy Documentation
Ralph R. Utzman, PT, MPH, PhD
Chapter 4: Documenting Patient/Client Management: An Overview
Mia L. Erickson, PT, EdD, CHT, ATC and Rebecca McKnight, PT, MS
Chapter 5: Documentation Formats
Mia L. Erickson, PT, EdD, CHT, ATC
Chapter 6: Rules for Writing in Medical Records
Mia L. Erickson, PT, EdD, CHT, ATC
Chapter 7: Documenting Patient Histories and Interviews
Ralph R. Utzman, PT, MPH, PhD
Chapter 8: Documenting Objective Information
Ralph R. Utzman, PT, MPH, PhD and Mia L. Erickson, PT, EdD, CHT, ATC
Chapter 9: Writing the Assessment and the Plan
Mia L. Erickson, PT, EdD, CHT, ATC and Rebecca McKnight, PT, MS
Chapter 10: Interim Documentation
Mia L. Erickson, PT, EdD, CHT, ATC and Rebecca McKnight, PT, MS
Chapter 11: Patient Outcomes and Discharge Summaries
Mia L. Erickson, PT, EdD, CHT, ATC
Chapter 12: Documentation and Reimbursement
Ralph R. Utzman, PT, MPH, PhD
Appendices
Appendix A Guidelines: Physical Therapy Documentation of Patient/Client Management
Appendix B Preferred Practice Patterns
Appendix C Sample Forms
Appendix D Abbreviations and Symbols
Appendix E Assessing Change
Glossary
Financial Disclosures
Index

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