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cover image - Documentation for Rehabilitation,3rd Edition
ISBN: 9780323312332
Page Count: 288
Imprint: Saunders
List Price: $57.95

Documentation for Rehabilitation, 3rd Edition

by Lori Quinn, EdD, PT and James Gordon, EdD, PT, FAPTA

Paperback

cover image - Documentation for Rehabilitation,3rd Edition
ISBN: 9780323312332
Page Count: 288
Imprint: Saunders
List Price: $57.95
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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.
  • I: THEORETICAL FOUNDATIONS
    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
    II: COMPONENTS OF PHYSICAL THERAPY DOCUMENTATION
    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  
    References
    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 of Movement Science and Kinesiology
    Director, Neurorehabilitation Research Lab
    Teachers College, Columbia University and James Gordon, EdD, PT, FAPTA, Professor and Associate Dean
    Division of Biokinesiology and Physical Therapy at the Herman Ostrow School of Dentistry
    University of Southern California
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Now $49.26
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