Documentation for Rehabilitation

A Guide to Clinical Decision Making in Physical Therapy

4th Edition - April 12, 2024
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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Better 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.

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

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