Documentation for Rehabilitation
A Guide to Clinical Decision Making in Physical Therapy
- 4th Edition - April 12, 2024
- Imprint: Elsevier
- Authors: Lori Quinn, James Gordon
- Language: English
- Paperback ISBN:9 7 8 - 0 - 3 2 3 - 6 9 4 3 0 - 8
- eBook ISBN:9 7 8 - 0 - 4 4 3 - 1 2 7 3 9 - 7
- eBook ISBN:9 7 8 - 0 - 3 2 3 - 6 9 4 3 2 - 2
- eBook ISBN:9 7 8 - 0 - 3 2 3 - 6 9 4 3 1 - 5
Better patient management starts with better documentation! Documentation for Rehabilitation, 4th Edition demonstrates how to accurately document treatment progress and pati… Read more
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Request a sales quoteBetter patient management starts with better documentation! Documentation for Rehabilitation, 4th Edition demonstrates how to accurately document treatment progress and patient outcomes using a framework for clinical reasoning based on the International Classification for Functioning, Disability, and Health (ICF) model adopted by the American Physical Therapy Association (APTA). The documentation guidelines in this practical resource are easily adaptable to different practice settings and patient populations in physical therapy and physical therapy assisting. Realistic examples and practice exercises reinforce the understanding and application of concepts, improving skills in both documentation and clinical reasoning.
- Workbook/textbook format with examples and exercises in each chapter helps reinforce understanding of concepts.
- Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, nursing homes, pediatrics, school, and community settings.
- Case examples for a multitude of documentation types include initial evaluations, progress notes, daily notes, letters to insurance companies, Medicare documentation, and documentation in specialized settings.
- Cover image
- Title page
- Table of Contents
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- Copyright
- Contributors
- Foreword
- Preface
- Acknowledgments
- Section I: Key Aspects of Clinical Documentation
- 1. Disablement Models and the ICF Framework
- THE CONCEPT OF DISABLEMENT AND THE ICF MODEL
- REHABILITATION IS ENABLEMENT: THE REVERSE OF DISABLEMENT
- FUNCTIONAL OUTCOMES: MORE THAN SIMPLY A DOCUMENTATION STRATEGY
- CLASSIFICATION ACCORDING TO THE ICF FRAMEWORK
- SUMMARY
- EXERCISE 1.1
- 2. Essentials of Documentation
- DOCUMENTATION: AN OVERVIEW
- TYPES OF NOTES
- PURPOSES OF NOTE WRITING
- DOCUMENTATION FORMATS
- WHAT CONSTITUTES “DOCUMENTATION”?
- EVIDENCE-BASED PRACTICE
- STRATEGIES FOR CONCISENESS IN DOCUMENTATION
- PERSON-FIRST LANGUAGE
- SUMMARY
- EXERCISE 2.1 INTERPRETING ABBREVIATIONS
- EXERCISE 2.2 CONCISE DOCUMENTATION AND USE OF ABBREVIATIONS
- EXERCISE 2.3 PEOPLE-FIRST LANGUAGE
- References
- 3. Legal Aspects of Documentation
- DOCUMENTATION AS A LEGAL RECORD
- PRIVACY OF THE MEDICAL RECORD: HIPAA AND THE PRIVACY RULE
- DOCUMENTATION OF INFORMED CONSENT
- POTENTIAL LEGAL ISSUES
- SUMMARY
- RECOMMENDED RESOURCES
- 4. Standardized Outcome Measures
- LEVELS OF MEASUREMENT
- PSYCHOMETRIC PROPERTIES
- INSTRUMENT SELECTION: CHOOSING APPROPRIATE OUTCOME MEASURES
- SUMMARY
- RECOMMENDED RESOURCES
- 5. Payment Policy and Coding
- THE BIG PICTURE OF HEALTH CARE REFORM AND PHYSICAL THERAPY
- THIRD-PARTY PAYERS
- PROSPECTIVE PAYMENT, BILLING, AND CODING
- CMS QUALITY PAYMENT PROGRAM
- SUMMARY
- RECOMMENDED RESOURCES
- 6. Electronic Medical Records
- DEVELOPING AND PRODUCING A PT EMR
- HOW ELECTRONIC DOCUMENTATION IMPROVES PRACTICE
- POTENTIAL PITFALLS WHEN USING ELECTRONIC DOCUMENTATION
- WHAT PAYERS AND OTHER STAKEHOLDERS WANT FROM THE MEDICAL RECORD
- SUMMARY
- Section II: Documenting the Initial Evaluation and Beyond: A Case-Based Guide
- 7. Clinical Decision-Making and the Initial Evaluation Format
- THE INITIAL EVALUATION FORMAT AND THE PHYSICAL THERAPIST MANAGEMENT PROCESS
- DESCRIPTION OF COMPONENTS OF THE INITIAL EVALUATION
- CASE EXAMPLES
- CONCLUSION
- SUMMARY
- EXERCISE 7.1
- 8. Documenting Reason for Referral: Health Condition and Participation
- HISTORY-TAKING FOR HEALTH CONDITIONS AND PARTICIPATION-BASED INFORMATION: THE FIRST STEP IN PHYSICAL THERAPY DIAGNOSIS
- DOCUMENTING REASON FOR REFERRAL
- SPECIFICITY OF DOCUMENTATION
- OUTCOME MEASURES
- PREVENTING PARTICIPATION RESTRICTIONS
- SUMMARY
- EXERCISE 8.1
- EXERCISE 8.2
- EXERCISE 8.3
- EXERCISE 8.4
- EXERCISE 8.5
- 9. Documenting Activities
- DEFINING AND CATEGORIZING ACTIVITIES
- DOCUMENTING TASK PERFORMANCE
- DOCUMENTING FUNCTIONAL ACTIVITIES
- MEASUREMENT OF ACTIVITIES
- STANDARDIZED TESTS AND MEASURES
- SUMMARY
- EXERCISE 9.1
- EXERCISE 9.2
- EXERCISE 9.3
- 10. Documenting Impairments in Body Structure and Function
- DEFINING AND CATEGORIZING IMPAIRMENTS
- SYSTEMS REVIEW
- STRATEGIES FOR DOCUMENTING IMPAIRMENTS
- STANDARDIZED TESTS AND MEASURES
- DOCUMENTING STRENGTH AND RANGE OF MOTION
- DOCUMENTING PAIN
- SUMMARY
- EXERCISE 10.1
- EXERCISE 10.2
- 11. Documenting the Assessment: Summary and Diagnosis
- DIAGNOSIS BY PHYSICAL THERAPISTS
- ASSESSMENT SECTION
- COMMON PITFALLS IN ASSESSMENT DOCUMENTATION
- SUMMARY
- EXERCISE 11.1
- CASE 1: OUTPATIENT
- CASE 2: OUTPATIENT
- CASE 3: INPATIENT
- CASE 4: OUTPATIENT
- CASE 5: INPATIENT REHABILITATION—BURN CENTER
- 12. Developing and Documenting Effective Goals
- THE GOAL-SETTING PROCESS
- A TRADITIONAL APPROACH: SHORT-TERM AND LONG-TERM GOALS
- WRITING GOALS AT THREE DIFFERENT LEVELS
- FUNDAMENTALS OF WELL-WRITTEN GOALS
- A FORMULA FOR WRITING GOALS - ABCDE
- THE ART OF WRITING PATIENT-CENTERED GOALS: GOING BEYOND THE FORMULA
- DETERMINING EXPECTED TIME FRAMES FOR GOALS
- CHOOSING WHICH GOALS TO MEASURE: PRIORITIZING AND BENCHMARKING
- GOAL ATTAINMENT SCALING
- WRITING PARTICIPATION AND IMPAIRMENT GOALS
- SUMMARY
- EXERCISE 12.1
- EXERCISE 12.2
- 13. Documenting the Plan of Care
- DOCUMENTING THE PLAN OF CARE
- DOCUMENTING SKILLED INTERVENTION
- DOCUMENTING INFORMED CONSENT
- SUMMARY
- EXERCISE 13.1
- 14. Session Notes and Progress Notes Using a Modified SOAP Format
- MODIFIED SOAP FORMAT
- SESSION NOTES
- SUMMARY
- EXERCISE 14.1
- EXERCISE 14.2
- EXERCISE 14.3
- EXERCISE 14.4
- 15. Special Formats: Screening Evaluations, Discharge Summaries, Letters, and Patient Education Materials
- SCREENING EVALUATIONS
- DISCHARGE SUMMARIES
- LETTERS TO THIRD-PARTY PAYERS TO JUSTIFY EQUIPMENT OR SERVICES
- PATIENT EDUCATION MATERIALS
- SUMMARY
- 16. Documentation in Pediatrics
- OVERVIEW
- EARLY INTERVENTION
- School-Based Intervention
- IDEA TO GOALS FRAMEWORK
- SUMMARY
- EXERCISE 16.1
- EXERCISE 16.2
- Recommended Resources
- References
- Appendix A. American Physical Therapy Association Position on Documentation
- PREAMBLE
- APTA POSITION ON DOCUMENTATION
- OPERATIONAL DEFINITIONS
- GENERAL GUIDELINES
- INITIAL EXAMINATION/EVALUATION
- VISIT/ENCOUNTER
- REEXAMINATION
- DISCHARGE/DISCONTINUATION SUMMARY
- EXPLANATION OF REFERENCE NUMBERS
- Appendix B. Rehabilitation Abbreviations
- GENERAL
- PROFESSIONAL
- MEDICAL DIAGNOSIS
- Symbols
- Abbreviations by Word
- Appendix C. Answers to Exercises
- CHAPTER 1
- CHAPTER 2
- CHAPTER 7
- CHAPTER 8
- CHAPTER 9
- CHAPTER 10
- CHAPTER 11
- CHAPTER 12
- CHAPTER 13
- CHAPTER 14
- CHAPTER 16
- Appendix D. Documentation Review Sample Checklist
- Appendix E. Sample Range of Motion and Strength Assessment Form
- Index
- Edition: 4
- Published: April 12, 2024
- Imprint: Elsevier
- No. of pages: 304
- Language: English
- Paperback ISBN: 9780323694308
- eBook ISBN: 9780443127397
- eBook ISBN: 9780323694322
- eBook ISBN: 9780323694315
LQ
Lori Quinn
Affiliations and expertise
Associate Professor of Movement Science and Kinesiology
Director, Neurorehabilitation Research Lab
Teachers College, Columbia UniversityJG
James Gordon
Affiliations and expertise
Professor and Associate Dean
Division of Biokinesiology and Physical Therapy at the Herman Ostrow School of Dentistry
University of Southern California