Documentation for Rehabilitation, 3rd Edition

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Documentation for Rehabilitation, 3rd Edition


Better patient management starts with better documentation! Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy, 3rd Edition shows how to accurately document treatment progress and patient outcomes. Designed for use by rehabilitation professionals, documentation guidelines are easily adaptable to different practice settings and patient populations. Realistic examples and practice exercises reinforce concepts and encourage you to apply what you’ve learned. Written by expert physical therapy educators Lori Quinn and James Gordon, this book will improve your skills in both documentation and clinical reasoning.

    • A practical framework shows how to organize and structure PT records, making it easier to document functional outcomes in many practice settings, and is based on the International Classification for Functioning, Disability, and Health (ICF) model — the one adopted by the APTA.
    • Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, and nursing homes, as well as a separate chapter on documentation in pediatric settings.
    • Guidelines to systematic documentation describe how to identify, record, measure, and evaluate treatment and therapies — especially important when insurance companies require evidence of functional progress in order to provide reimbursement.
    • Workbook/textbook format uses examples and exercises in each chapter to reinforce your understanding of concepts.
      • NEW Standardized Outcome Measures chapter leads to better care and patient management by helping you select the right outcome measures for use in evaluations, re-evaluations, and discharge summaries.
      • UPDATED content is based on data from current research, federal policies and APTA guidelines, including incorporation of new terminology from the Guide to Physical Therapist 3.0 and ICD-10 coding.
      • EXPANDED number of case examples covers an even broader range of clinical practice areas.
      1. Disablement Models, ICF Framework and Clinical Decision Making
      2. Essentials of Documentation
      3. Legal Aspects of Documentation
      4. Standardized Outcome Measures  NEW!
      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
      11. Document the Assessment: Summary and Diagnosis
      12. Developing and Documenting Effective Goals
      13. Documenting the Plan of Care
      14. Documenting Session Notes and Progress Notes Using a Modified SOAP Note Format
      15. Special Formats: Documenting Screenings, Discharge Summaries, Letters and Patient Education Materials
      16. Documentation in Pediatrics  
      Appendix A:  Guidelines: Physical Therapy Documentation of Patient/Client Management
      Appendix B: Rehabilitation Abbreviations
      Appendix C: Answers to Exercises
      Appendix D:  Documentation Review Sample Checklist
        Appendix E: Strength and Range of Motion Forms
      Lori Quinn, EdD, PT, Associate Professor, Program in Physical Therapy, New York Medical College, School of Public Health, Valhalla, NY and James Gordon, EdD, PT, Associate Professor and Chair, Department of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA


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