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Ensure confident clinical decisions and maximum reimbursement in a variety of practice settings such as acute care, outpatient, home care, and nursing homes with the only systematic approach to documentation for rehabilitation professionals! Revised and expanded, this hands-on textbook/workbook provides a unique framework for maintaining evidence of treatment progress and patient outcomes with a clear, logical progression. Extensive examples and exercises in each chapter reinforce concepts and encourage you to apply what you’ve learned to realistic practice scenarios.
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