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Documentation for Rehabilitation

Documentation for Rehabilitation

A Guide to Clinical Decision Making in Physical Therapy

9780323312332
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Description

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 youve learned. Written by expert physical therapy educators Lori Quinn and James Gordon, this book will improve your skills in both documentation and clinical reasoning.

Product Details
Saunders
58154
9780323312332
9780323312332

Data sheet

Publication date
2016
Issue number
3
Cover
paperback
Pages count
288
Dimensions (mm)
216 x 276
Weight (g)
590
  • 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
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