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Documentation for Rehabilitation

Documentation for Rehabilitation

A Guide to Clinical Decision Making in Physical Therapy

9780323694308
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Description

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.

Product Details
Elsevier
99696
9780323694308
9780323694308

Data sheet

Publication date
2024
Issue number
4
Cover
paperback
Pages count
304
Dimensions (mm)
216 x 276
Weight (g)
510
  • 1. Disablement Models and the ICF Framework
    2. Essentials of Documentation
    3. Legal Aspects of Documentation
    4. Standardized Outcome Measures
    5. Payment Policy and Coding
    6. Electronic Medical Records
    7. Clinical Decision-Making and the Initial Evaluation Format
    8. Documenting Reason for Referral: Health Condition and Participation
    9. Documenting Activities
    10. Documenting Impairments in Body Structure and Function
    11. Documenting the Assessment: Summary and Diagnosis
    12. Developing and Documenting Effective Goals
    13. Documenting the Plan of Care
    14. Session Notes and Progress Notes Using a Modified SOAP Format
    15. Special Formats: Screening Evaluations, Discharge Summaries, Letters, and Patient Education Materials
    16. Documentation in Pediatrics
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