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Communicating Clinical Decision-Making Through Documentation: Coding, Payment, and Patient Categorization

Communicating Clinical Decision-Making Through Documentation: Coding, Payment, and Patient Categorization

9781260440669
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Description

Publishers Note:: Products purchased from Third Party sellers are not guaranteed by the publisher for quality, authenticity, or access to any online entitlements included with the product.

Clear, concise, and simple to follow—everything you need to master the documentation process quickly and easily

Communicating Clinical Decision Making Through Documentation is the top choice for professionals and students seeking complete coverage of the documentation process including billing and coding. It shows how to ensure every service rendered and billed is supported by showing what to document, how to do it, and why it is so important.

This text includes a refreshing student-friendly approach to the topic. You will find an abundance of cases portraying real-life case scenarios and it delivers must-know information on writing patient/client care notes, incorporating document guidelines, documenting clinical decision making (includes evidence-based practice), and performing billing and coding tasks.

With Communicating Clinical Decision Making Through Documentation, youll effectively maintain and organize records, record appropriate information, and receive proper payment based on the documentation content.

A to Z coverage of physical therapy documentation, including::

  • Documentation Standards and Guidelines
  • Medicare
  • Home Health
  • Electronic Medical Records (EMR)
  • International Classification of Functioning (ICF) Model and Application
  • Pediatrics
  • Legal Issue
  • Utilization Review & Management
  • Skilled Nursing Facilities
  • Sample Documentation Content
  • Initial Examination and Evaluation Criteria
  • Continuum of Care Content and Goal Writing Exercises
  • Documentation Aspects of Supervising PTAs
  • Abbreviations
  • Payment
  • ICD-10 and CPT Codes and Application
  • Chapter Review Questions
  • Content Principles





Product Details
60818
9781260440669
9781260440669

Data sheet

Publication date
2021
Issue number
1
Cover
paperback
Dimensions (mm)
218 x 274
Weight (g)
1302
  • Contents
    Contributors
    Preface
    Acknowledgements

    SECTION 1 How to Write Patient Care Notes
    1. Introduction, Background, Purpose, and General Rules for Health Information Management
    2. Record Organization and General Principles
    3. Application of Models for Organization and Guidelines for Content
    4. The Electronic Medical Record
    5. Content Standardization and Component Requirements
    6. Documentation for Pediatrics
    7. Documentation for Home Health
    8. Documentation for Certified Nursing Homes

    SECTION 2 How to Document Clinical Decision-Making
    9. Evidence-Based Practice
    10. Clinical Decision-Making
    11. Legal Issues in the Medical Record
    12. Utilization Review and Utilization Management

    SECTION 3 Payment and Coding
    13. Coding
    14. Documentation Content Principles
    15. Alternative Payment Models

    SECTION 4 Steps and Framework for Coding and Documentation
    16. Documentation Writing Examples and Worksheets

    Appendix A Abbreviations
    Appendix B OASIS D
    Appendix C CMS Form 1500 with Instructions
    Appendix D ICD-10 Guidelines
    Appendix E APTA Guidelines for Physical Therapy Documentation
    Appendix F APTA Documentation Review Checklist

    Index
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