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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

Market/Audience

Physical Therapy Students

Product Details
McGraw Hill / Medical
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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