Functional outcomes are at the core of physical therapy practice, helping to improve client function and reduce disability. Documentation allows therapists to identify, record, measure, and evaluate treatments and therapies in a uniform record, as well as providing evidence of functional progress for insurance payment and reimbursement. This hands-on textbook/workbook teaches users to document functional outcomes in a clear, logical progression.
Section 1 - Theoretical Foundations 1. Introduction 2. Essentials of documentation 3. Overview of the Functional Outcomes Approach to Documentation: The Initial Evaluation Format
Section 2 - Implementing a Functional Outcomes Approach to Documentation 4. Documenting Reason for referral: medical diagnosis and pathology 5. Documenting reason for referral: disability and social history 6. Documenting Functional limitations 7. Documenting Impairments 8. Documenting Assessment and PT Diagnosis 9. Documenting Goals 10. Documenting Intervention Plan
Section 3 - Alternative Documentation Formats 11. Progress note format - elements of the SOAP note 12. Specialized documentation 13. Computerized documentation
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