Documentation for Rehabilitation

I. Theoretical Foundations & Documentation Essentials 1. Disablement models, ICF Framework, and Clinical Decision Making 2. Essentials of Documentation 3. Legal Aspects of Documentation - New 4. Clinical Decision Making and the Initial Evaluation Format

II. Components of Physical Therapy Documentation 5. Documenting History: Background Information and Health Condition 6. Documenting History: Participation and Social History 7. Documenting Activities 8. Documenting Impairments in Body Structure and Function 9. Documenting the Assessment: Summary and Diagnosis 10. Documenting Goals 11. Documenting the Plan of Care 12. Daily Notes and Progress Notes using a Modified SOAP Format

III. Additional Documentation Forms 13. Specialized Documentation 14. Documentation in Pediatrics - New 15. Payment Policy and Coding - New 16. Computerized Documentation - New

References Appendix A. Guidelines for Physical Therapy Documentation Appendix B. Rehabilitation Abbreviations Appendix C. Answers to Exercises Appendix D. Sample Evaluation Forms