Documentation for Rehabilitation - Elsevier eBook on VitalSource (Retail Access Card), 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.
- 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.
- Four NEW chapters address additional aspects of documentation that rehabilitation professionals will encounter in practice:
- Legal aspects of documentation
- Documentation in pediatrics
- Payment policy and coding
- Computerized documentation
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
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