Documentation for Rehabilitation - E-Book: A Guide to Clinical Decision Making in Physical Therapy

by PT Quinn EdD, PT Gordon EdD

Overview

- NEW Standardized Outcome Measures chapter leads to better care and patient management by helping you select the right outcome measures for use in evaluations, re-evaluations, and discharge summaries. - UPDATED content is based on data from current research, federal policies and APTA guidelines, including incorporation of new terminology from the Guide to Physical Therapist 3.0 and ICD-10 coding. - EXPANDED number of case examples covers an even broader range of clinical practice areas.

Product Details

ISBN-13:	9780323312349
Publisher:	Saunders, W. B. Company
Publication date:	11/18/2015
Sold by:	Barnes & Noble
Format:	eBook
Pages:	288
File size:	10 MB

Table of Contents

I: THEORETICAL FOUNDATIONS1. Disablement Models, ICF Framework and Clinical Decision Making2. Essentials of Documentation3. Legal Aspects of Documentation 4. Standardized Outcome Measures  NEW!5. Payment Policy and Coding6 Electronic Medical RecordsII: COMPONENTS OF PHYSICAL THERAPY DOCUMENTATION7. Clinical Decision Making and the Initial Evaluation Format  8. Documenting Reason for Referral: Health Condition and Participation9. Documenting Activities10. Documenting Impairments11. Document the Assessment: Summary and Diagnosis 12. Developing and Documenting Effective Goals13. Documenting the Plan of Care14. Documenting Session Notes and Progress Notes Using a Modified SOAP Note Format15. Special Formats: Documenting Screenings, Discharge Summaries, Letters and Patient Education Materials16. Documentation in Pediatrics  ReferencesAppendix A:  Guidelines: Physical Therapy Documentation of Patient/Client ManagementAppendix B: Rehabilitation AbbreviationsAppendix C: Answers to ExercisesAppendix D:  Documentation Review Sample Checklist  Appendix E: Strength and Range of Motion Forms