Effective Documentation for Physical Therapy Professionals, Second Edition / Edition 2

by Debra F. Stern, Eric Shamus

Overview

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Everything the physical therapists needs to know about the documentation process in one clear, concise, easy-to-follow text

Effective Documentation for Physical Therapy Professionals is your best choice for gaining a solid understanding of the entire physical therapy documentation process. There is no faster or easier way to learn the when, what, and how of physical therapy documentation than this trusted guide. The second edition has been updated to include the most recent professional guidelines, codes, and methodologies and covers timely subjects such as Medicare, electronic record keeping, legal issues, pediatric documentation, utilization review and management, and much more.

With Effective Documentation for Physical Therapy Professionals, you will learn how to incorporate all of the general principles of documentation and health information management in order to effectively maintain and organize records, record appropriate information, and receive proper reimbursement based on the documentation content.

Master All Aspects of PT Documentation With:
APTA Standards and Guidelines,Medicare,Home Health,Electronic Record Keeping,ICF Model and Application,Pediatrics,Legal Issues,Utilization Review & Management,SNF: RUGS and MDS,Sample Documentation Content,Initial Examination and Evaluation Criteria,Continuum of Care Content and Goal Writing Exercises,Documentation Aspects of Supervising PTAs,Abbreviations,Reimbursement,ICD9 and CPT Codes and Application,Chapter Review Questions,Content Principles.

Product Details

ISBN-13:	9780071664042
Publisher:	McGraw Hill LLC
Publication date:	05/23/2011
Edition description:	New Edition
Pages:	352
Product dimensions:	8.40(w) x 10.80(h) x 0.40(d)

About the Author

Debra F. Stern, PT, MSM, DBA is an Associate Professor at Nova Southeastern University in Fort Lauderdale, FL. She serves as a clinical instructor with a focus on geriatrics, neuromuscular disorders, and also coordinates service learning experiences for the school's PT department. She received her BS in Physical Therapy from SUNY Buffalo, her MSM from Rollins College, and her DBAS at Nova Southeastern.

Author Profiles

Eric Shamus, DPT, PhD, CSCS has taught national and international continuing education courses on Orthopeadics, Sports Medicine, and Manual Therapy, with a focus on documentation and reimbursement. He is presently a professor at Florida Gulf Coast University and works at an outpatient orthopedic facility in Fort Lauderdale.

Debra F. Stern, PT, MSM, DBA is an Associate Professor at Nova Southeastern University in Fort Lauderdale, FL. She serves as a clinical instructor with a focus on geriatrics, neuromuscular disorders, and also coordinates service learning experiences for the school's PT department. She received her BS in Physical Therapy from SUNY Buffalo, her MSM from Rollins College, and her DBAS at Nova Southeastern.

Table of Contents

Chapter 1. Introduction, Background, Purpose and General Rules for Health Information Management (Medical Record Keeping)Chapter 2. Record Organization and General PrinciplesChapter 3. Application of Models for Organization and Guidelines for ContentChapter 4. Content Standardization/Component RequirementsChapter 5. Coding and DocumentationChapter 6. Home Health DocumentationChapter 7. Legal Issues in the Medical RecordChapter 8. MDS Purpose and ComponentsChapter 9. Medicare and Non-Medicare Content PrinciplesChapter 10. Pediatric DocumentationChapter 11. The Electronic Medical RecordChapter 12. Utilization Review and Utilization ManagementAppendix A: AbbreviationsAppendix B: CMS 700 Form and CS-1786 HIPPA Disclosure FormAppendix C: CMS Forms 1450 and 1500 with InstructionsAppendix D: ICD-9 Code TermsAppendix E: APTA Guidelines for Physical Therapy Documentation and Guidelines for Group CodingAppendix F: Goal Writing ExerciseAppendix G: Note Writing ExerciseAppendix H: Documentation Content ExerciseAppendix I: Documentation Content Examples

Editorial Reviews

Reviewer: Lauren Y Perrone, MPT, OCS (Head 2 Toe Physical Therapy)
Description: This updated book presents general principles of documentation for physical therapy services and how to effectively manage health information to receive reimbursement. The previous edition was published in 2004.
Purpose: The purpose is to provide current information on documentation to avoid denial of medically necessary physical therapy services. The book highlights common errors that result in denial of skilled physical therapy and describes how to organize the medical record and choose the most appropriate content. The authors meet their objectives, providing a valuable resource on what, how, and why to document.
Audience: It is written for physical therapy professionals at all experience levels. It provides a solid foundation for students as well as review and reflection for more experienced clinicians. In today's healthcare environment, it is imperative that physical therapists document effectively. The authors have selected an extensive group of professionals to contribute the most current knowledge to the book.
Features: The first four chapters summarize the general rules for health information management and the principles, guidelines, and requirements for effective documentation. It then dives into special topics including home health and pediatric documentation, as well as legal issues and utilization review. The chapter outlining Medicare and non-Medicare content principles is well done with multiple case studies, sample problem lists, goals, and treatment notes to enhance learning. Throughout, Author's Notes offer clarifications and exceptions to the rule. Chapters conclude with up-to-date references, essential for this topic, and review questions. The appendixes that follow the chapters serve as a convenient reference for use in the clinic, and include abbreviations, ICD-9 code terms, Medicare and HIPPA forms, and goal writing and documentation content exercises.
Assessment: This is a valuable and practical book for students and experienced clinicians alike. This update is justified due to the dynamic quality of the material. With reimbursement decreasing for skilled physical therapy services, it is imperative that documentation is detailed and accurate about what is billed. I strongly recommend this book for physical therapy programs and as an essential update for all practicing clinicians.

Doody's Review Service

3 Stars from Doody