Documentation for Rehabilitation - Elsevier eBook on VitalSource (Retail Access Card), 3rd Edition
Elsevier eBook on VitalSource - Access Card
$46.99
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.
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- UNIQUE! Combination textbook/workbook format reinforces your understanding and tests your ability to apply concepts through practice exercises.
- UNIQUE! Systematic approach to documenting functional outcomes provides a practical framework for success in numerous practice settings.
- Case studies show you how to format goals through realistic client examples.
- Practice exercises provide valuable experience applying concepts to common clinical problems.
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- 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.
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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