Documentation for Rehabilitation

A Guide to Clinical Decision Making in Physical Therapy

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Brand: Elsevier

ISBN: 9780323694308

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Scheduled publishing date: 2024-07-26

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Description

Better patient management starts with better documentation! Documentation for Rehabilitation, 4^th 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

Brand Elsevier

Reference 99696

EAN13 9780323694308

ISBN 9780323694308

Data sheet

Publication date: 2024
Issue number: 4
Cover: paperback
Pages count: 304
Dimensions (mm): 215 x 276
Weight (g): 450

Section 1: Key Aspects of Clinical Documentation
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 Record
Section 2: Documenting the Initial Evaluation and Beyond: A Case-Based Guide
7. Clinical Decision Making and the Initial Evaluation Format
8. Documenting Reason for Referral: Health Condition and Participation
9. Documenting Activities
10. NEW! Movement Analysis - Linking Activities and Impairments
11. Documenting Impairments in Body Structure and Function
12. Documenting the Assessment: Summary and Diagnosis
13. Developing and Documenting Effective Goals
14. Documenting the Plan of Care
15. Session Notes and Progress Notes Using a Modified SOAP Format
16. Special Formats: Screening Evaluations, Discharge Summaries, Letters, and Patient Education Materials
17. Documentation in Pediatrics
References
Appendix A: Guidelines for Physical Therapy Documentation
Appendix B: Rehabilitation Abbreviations
Appendix C: Answers to Exercises
Appendix D: Documentation Review Sample Checklist
Appendix E: Sample Range of Motion and Strength Assessment Form