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Documentation for Rehabilitation

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Muestra
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Descripción

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.

1. Cover image - p. i 2. Title page - p. i 3. Table of Contents - p. i 4. Copyright - p. iv 5. Dedication - p. v 6. Contributors - p. vii 7. Foreword - p. viii 8. Preface - p. ix 9. Acknowledgments - p. xi 10. Section I Key Aspects of Clinical Documentation - p. xi 11. Chapter 1 Disablement Models and the ICF Framework - p. 1 12. Chapter 2 Essentials of Documentation - p. 8 13. Chapter 3 Legal Aspects of Documentation - p. 21 14. Chapter 4 Standardized Outcome Measures - p. 28 15. Chapter 5 Payment Policy and Coding - p. 35 16. Chapter 6 Electronic Medical Record - p. 56 17. Section II Documenting the Initial Evaluation and Beyond: A Case‐Based Guide - p. 64 18. Chapter 7 Clinical Decision Making and the Initial Evaluation Format - p. 69 19. Chapter 8 Documenting Reason for Referral: Health Condition and Participation - p. 88 20. Chapter 9 Documenting Activities - p. 107 21. Chapter 10 Documenting Impairments in Body Structure and Function - p. 121 22. Chapter 11 Documenting the Assessment: Summary and Diagnosis - p. 132 23. Chapter 12 Developing and Documenting Effective Goals - p. 143 24. Chapter 13 Documenting the Plan of Care - p. 157 25. Chapter 14 Session Notes and Progress Notes Using a Modified SOAP Format - p. 166 26. Chapter 15 Special Formats: Screening Evaluations, Discharge Summaries, Letters, and Patient Education Materials - p. 182 27. Chapter 16 Documentation in Pediatrics - p. 203 28. References - p. 222 29. Appendix A Guidelines for Physical Therapy Documentation - p. 227 30. Appendix B Rehabilitation Abbreviations - p. 233 31. Appendix C Answers to Exercises - p. 243 32. Appendix D Documentation Review Sample Checklist - p. 258 33. Appendix E Sample Range of Motion and Strength Assessment Form - p. 261 34. Index - p. 262

Descripcion
Descripción

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.

1. Cover image - p. i 2. Title page - p. i 3. Table of Contents - p. i 4. Copyright - p. iv 5. Dedication - p. v 6. Contributors - p. vii 7. Foreword - p. viii 8. Preface - p. ix 9. Acknowledgments - p. xi 10. Section I Key Aspects of Clinical Documentation - p. xi 11. Chapter 1 Disablement Models and the ICF Framework - p. 1 12. Chapter 2 Essentials of Documentation - p. 8 13. Chapter 3 Legal Aspects of Documentation - p. 21 14. Chapter 4 Standardized Outcome Measures - p. 28 15. Chapter 5 Payment Policy and Coding - p. 35 16. Chapter 6 Electronic Medical Record - p. 56 17. Section II Documenting the Initial Evaluation and Beyond: A Case‐Based Guide - p. 64 18. Chapter 7 Clinical Decision Making and the Initial Evaluation Format - p. 69 19. Chapter 8 Documenting Reason for Referral: Health Condition and Participation - p. 88 20. Chapter 9 Documenting Activities - p. 107 21. Chapter 10 Documenting Impairments in Body Structure and Function - p. 121 22. Chapter 11 Documenting the Assessment: Summary and Diagnosis - p. 132 23. Chapter 12 Developing and Documenting Effective Goals - p. 143 24. Chapter 13 Documenting the Plan of Care - p. 157 25. Chapter 14 Session Notes and Progress Notes Using a Modified SOAP Format - p. 166 26. Chapter 15 Special Formats: Screening Evaluations, Discharge Summaries, Letters, and Patient Education Materials - p. 182 27. Chapter 16 Documentation in Pediatrics - p. 203 28. References - p. 222 29. Appendix A Guidelines for Physical Therapy Documentation - p. 227 30. Appendix B Rehabilitation Abbreviations - p. 233 31. Appendix C Answers to Exercises - p. 243 32. Appendix D Documentation Review Sample Checklist - p. 258 33. Appendix E Sample Range of Motion and Strength Assessment Form - p. 261 34. Index - p. 262

Indice
Autores
Muestra
Ficha Técnica