Documentation for Rehabilitation
A Guide to Clinical Decision Making in Physical Therapy
- 3rd Edition - December 11, 2015
- Latest edition
- Authors: Lori Quinn, James Gordon
- Language: English
Better patient management starts with better documentation! Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy, 3rd Edition shows how to acc… Read more
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Better patient management starts with better documentation! Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy, 3rd Edition shows how to accurately document treatment progress and patient outcomes. Designed for use by rehabilitation professionals, documentation guidelines are easily adaptable to different practice settings and patient populations. Realistic examples and practice exercises reinforce concepts and encourage you to apply what you’ve learned. Written by expert physical therapy educators Lori Quinn and James Gordon, this book will improve your skills in both documentation and clinical reasoning.
- A practical framework shows how to organize and structure PT records, making it easier to document functional outcomes in many practice settings, and is based on the International Classification for Functioning, Disability, and Health (ICF) model — the one adopted by the APTA.
- Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, and nursing homes, as well as a separate chapter on documentation in pediatric settings.
- Guidelines to systematic documentation describe how to identify, record, measure, and evaluate treatment and therapies — especially important when insurance companies require evidence of functional progress in order to provide reimbursement.
- Workbook/textbook format uses examples and exercises in each chapter to reinforce your understanding of concepts.
I: THEORETICAL FOUNDATIONS
1. Disablement Models, ICF Framework and Clinical Decision Making
2. Essentials of Documentation
3. Legal Aspects of Documentation
4. Standardized Outcome Measures NEW!
5. Payment Policy and Coding
6 Electronic Medical Records
II: COMPONENTS OF PHYSICAL THERAPY DOCUMENTATION
7. Clinical Decision Making and the Initial Evaluation Format
8. Documenting Reason for Referral: Health Condition and Participation
9. Documenting Activities
10. Documenting Impairments
11. Document the Assessment: Summary and Diagnosis
12. Developing and Documenting Effective Goals
13. Documenting the Plan of Care
14. Documenting Session Notes and Progress Notes Using a Modified SOAP Note Format
15. Special Formats: Documenting Screenings, Discharge Summaries, Letters and Patient Education Materials
16. Documentation in Pediatrics
References
Appendix A: Guidelines: Physical Therapy Documentation of Patient/Client Management
Appendix B: Rehabilitation Abbreviations
Appendix C: Answers to Exercises
Appendix D: Documentation Review Sample Checklist
Appendix E: Strength and Range of Motion Forms
1. Disablement Models, ICF Framework and Clinical Decision Making
2. Essentials of Documentation
3. Legal Aspects of Documentation
4. Standardized Outcome Measures NEW!
5. Payment Policy and Coding
6 Electronic Medical Records
II: COMPONENTS OF PHYSICAL THERAPY DOCUMENTATION
7. Clinical Decision Making and the Initial Evaluation Format
8. Documenting Reason for Referral: Health Condition and Participation
9. Documenting Activities
10. Documenting Impairments
11. Document the Assessment: Summary and Diagnosis
12. Developing and Documenting Effective Goals
13. Documenting the Plan of Care
14. Documenting Session Notes and Progress Notes Using a Modified SOAP Note Format
15. Special Formats: Documenting Screenings, Discharge Summaries, Letters and Patient Education Materials
16. Documentation in Pediatrics
References
Appendix A: Guidelines: Physical Therapy Documentation of Patient/Client Management
Appendix B: Rehabilitation Abbreviations
Appendix C: Answers to Exercises
Appendix D: Documentation Review Sample Checklist
Appendix E: Strength and Range of Motion Forms
"A clear and concise message with a rigid format which has something for newbies and seasoned pros"
"easily accessible, easy to follow and easy to use with enough complexity to cater for all needs."
- Edition: 3
- Latest edition
- Published: December 11, 2015
- Language: English
LQ
Lori Quinn
Affiliations and expertise
Associate Professor of Movement Science and KinesiologyDirector, Neurorehabilitation Research LabTeachers College, Columbia University, USAJG
James Gordon
Affiliations and expertise
Professor and Associate DeanDivision of Biokinesiology and Physical Therapy, Herman Ostrow School of Dentistry, University of Southern California, USA