ISBN-10:
0803638205
ISBN-13:
9780803638204
Pub. Date:
05/07/2016
Publisher:
F. A. Davis Company
Writing Patient/Client Notes: Ensuring Accuracy in Documentation / Edition 5

Writing Patient/Client Notes: Ensuring Accuracy in Documentation / Edition 5

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Overview

Writing Patient/Client Notes: Ensuring Accuracy in Documentation / Edition 5

Master the hows and whys of documentation!

Develop all of the skills you need to write clear, concise, and defensible patient/client care notes using a variety of tools, including SOAP notes.

This is the ideal resource for any health care professional needing to learn or improve their skills—with simple, straight forward 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 and WHO’s ICF model.

Section by section you’ll learn how to document clearly and accurately, while exercise by exercise you’ll practice mastering every step.

Product Details

ISBN-13: 9780803638204
Publisher: F. A. Davis Company
Publication date: 05/07/2016
Edition description: Revised
Pages: 288
Sales rank: 575,651
Product dimensions: 8.40(w) x 10.90(h) x 0.80(d)

Table of Contents

1. Introduction to Documentation



I. The Health Record

2. Overview of the Health Record

3. Legal Aspects of the Health Record

4. Reimbursement

5. Reviewing the Health Record as a Physical Therapist



II. Documentation Basics

6. Writing in a Health Record

7. Introduction to Note Writing

8. Medical Terminology

9. Using Abbreviations

10. Introduction to Documentation Using the International Classification of Functioning, Disability, and Health (ICF) System



III. Documenting the Examination

11. The Patient/Client Management Format: Writing History, Including the Review of Systems

12. The Patient/Client Management Format: Writing Systems Review and Tests and Measures

13. The SOAP Note: Stating the Problem

14. The SOAP Note: Writing Subjective (S), Including the Review of Systems

15. The SOAP Note: Writing Objective (O)



IV. Documenting the Evaluation/Assessment (A)

16. Writing the Evaluation / Assessment (A)

17. Writing the Diagnosis (A: DIAGNOSIS)

18. Writing the Prognosis (A: PROGNOSIS)

V. Documenting the Plan of Care (P)

19. Writing Expected Outcomes and Anticipated Goals

20. Documenting the Intervention Plan

VI. Applications of Documentation Skills

21. Writing the Daily Visit Notes

22. The Medicare Therapy Cap, KX Modifiers, and Functional Limitations Reporting (G Codes)

23. Applications and Variations in Note Writing



Appendices

A. Summary of the Patient/Client Management Note Contents

B. Summary of the SOAP Note Contents

C. Summary of Contents of the Four Types of Notes

D. Tips for Note Writing for Third Party Payers

E. Review of Systems and Systems Review Forms

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