Writing Patient/Client Notes: Ensuring Accuracy in Documentation / Edition 4

Paperback (Print)
Rent from BN.com
(Save 69%)
Est. Return Date: 07/21/2015
Used and New from Other Sellers
Used and New from Other Sellers
from $23.87
Usually ships in 1-2 business days
(Save 40%)
Other sellers (Paperback)
  • All (10) from $23.87   
  • New (7) from $25.97   
  • Used (3) from $23.87   


An ideal resource for any health care professional needing to learn or improve their skills—with simple, straightforward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management model. Section by section, exercise by exercise, the 4th Edition will help you to to write clear, concise, and correct patient care notes using a variety of tools, including SOAP notes.

Read More Show Less

Product Details

  • ISBN-13: 9780803618787
  • Publisher: F. A. Davis Company
  • Publication date: 2/28/2009
  • Edition description: New Edition
  • Edition number: 4
  • Pages: 256
  • Sales rank: 163,790
  • Product dimensions: 8.40 (w) x 10.70 (h) x 0.70 (d)

Table of Contents

How to Use This Book

I. Background Information

1. Introduction to Note Writing

2. Writing in a Medical Record

3. Medical Terminology/Worksheets

4. Using Abbreviations/Worksheets

II. Documenting the Examination

5. The Patient/Client Management Format: Writing History/Worksheets

6. The Patient/Client Management Format: Writing Systems Review/Worksheets

7. The Patient/Client Management Format: Documenting Tests and Measures/Worksheets Review Worksheet: Writing the History, Systems Review, and Tests and Measures

8. The SOAP Note: Stating the Problem

9. The SOAP Note: Writing Subjective (S)/Worksheets

10. The SOAP Note: Writing Objective (O)/Worksheets Review Worksheet: Stating the Problem, S & O

III. Documenting the Evaluation (A)

11. Writing Evaluation

12. Writing the Diagnosis

13. Writing the Prognosis/Worksheets Review Worksheet: History, Systems Review, Tests & Measures, Evaluation, Diagnosis, Prognosis Review Worksheet: Problem, S, O, A VI. Documenting the Plan of Care (P)

14. Writing Expected Outcomes (Long Term Goals)/Worksheets

15. Writing Anticipated Goals (Short Term Goals)/Worksheets

16. Documenting Planned Interventions/Worksheets Final Review Worksheet: Patient/Client Management Note: History, Systems Review, Tests & Measures, Evaluation, Diagnosis, Prognosis, Plan of Care Final Review Worksheet: Problem, S, O, A, P V. The Medical Record

17. Overview of the Medical Record

18. Legal Issues

19. Reimbursement

VI. Applications of Documentation Skills

20. Applications and Variations in Note Writing

21. Alternatives: Documentation Forms and Computerized Documentation

22. The Future: Documentation Using the ICF System

Appendix A: Answers to Worksheets

Appendix B: Summary of the Patient/Client Management Note Contents

Appendix C: Summary of the SOAP Note Contents

Appendix D: Tips for Note Writing for Third Party Payers

Read More Show Less

Customer Reviews

Be the first to write a review
( 0 )
Rating Distribution

5 Star


4 Star


3 Star


2 Star


1 Star


Your Rating:

Your Name: Create a Pen Name or

Barnes & Noble.com Review Rules

Our reader reviews allow you to share your comments on titles you liked, or didn't, with others. By submitting an online review, you are representing to Barnes & Noble.com that all information contained in your review is original and accurate in all respects, and that the submission of such content by you and the posting of such content by Barnes & Noble.com does not and will not violate the rights of any third party. Please follow the rules below to help ensure that your review can be posted.

Reviews by Our Customers Under the Age of 13

We highly value and respect everyone's opinion concerning the titles we offer. However, we cannot allow persons under the age of 13 to have accounts at BN.com or to post customer reviews. Please see our Terms of Use for more details.

What to exclude from your review:

Please do not write about reviews, commentary, or information posted on the product page. If you see any errors in the information on the product page, please send us an email.

Reviews should not contain any of the following:

  • - HTML tags, profanity, obscenities, vulgarities, or comments that defame anyone
  • - Time-sensitive information such as tour dates, signings, lectures, etc.
  • - Single-word reviews. Other people will read your review to discover why you liked or didn't like the title. Be descriptive.
  • - Comments focusing on the author or that may ruin the ending for others
  • - Phone numbers, addresses, URLs
  • - Pricing and availability information or alternative ordering information
  • - Advertisements or commercial solicitation


  • - By submitting a review, you grant to Barnes & Noble.com and its sublicensees the royalty-free, perpetual, irrevocable right and license to use the review in accordance with the Barnes & Noble.com Terms of Use.
  • - Barnes & Noble.com reserves the right not to post any review -- particularly those that do not follow the terms and conditions of these Rules. Barnes & Noble.com also reserves the right to remove any review at any time without notice.
  • - See Terms of Use for other conditions and disclaimers.
Search for Products You'd Like to Recommend

Recommend other products that relate to your review. Just search for them below and share!

Create a Pen Name

Your Pen Name is your unique identity on BN.com. It will appear on the reviews you write and other website activities. Your Pen Name cannot be edited, changed or deleted once submitted.

Your Pen Name can be any combination of alphanumeric characters (plus - and _), and must be at least two characters long.

Continue Anonymously
Sort by: Showing all of 2 Customer Reviews
  • Anonymous

    Posted May 1, 2011

    No text was provided for this review.

  • Anonymous

    Posted March 13, 2011

    No text was provided for this review.

Sort by: Showing all of 2 Customer Reviews

If you find inappropriate content, please report it to Barnes & Noble
Why is this product inappropriate?
Comments (optional)