This product is available without an access card. Click the button below to get instant access now.
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.
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