Overview

Master the hows and whys of documentation! Develop all of the skills you need to write clear, concise, and defensible patient/client care notes using a variety of tools, including SOAP notes. This is the ideal resource for any health care professional needing to learn or improve their skills—with simple, straight forward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management and WHO’s ICF model. Section by section you’ll learn how to document clearly and accurately, while exercise by exercise you’ll practice mastering every step.

Full Product Details

Author:   Ginge Kettenbach ,  Sarah Lynn Schlomer ,  Jill Fitzgerald
Publisher:   F.A. Davis Company
Imprint:   F.A. Davis Company
Edition:   Fifth Edition
Dimensions:   Width: 21.60cm , Height: 1.90cm , Length: 27.90cm
Weight:   0.706kg
ISBN:  

9780803638204

ISBN 10:   0803638205
Pages:   304
Publication Date:   30 May 2016
Audience:   Professional and scholarly ,  Professional & Vocational
Format:   Paperback
Publisher's Status:   Active
Availability:   In Print  
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Table of Contents

1. Introduction to Documentation I. The Health Record 2. Overview of the Health Record 3. Legal Aspects of the Health Record 4. Reimbursement 5. Reviewing the Health Record as a Physical Therapist II. Documentation Basics 6. Writing in a Health Record 7. Introduction to Note Writing 8. Medical Terminology 9. Using Abbreviations 10. Introduction to Documentation Using the International Classification of Functioning, Disability, and Health (ICF) System III. Documenting the Examination 11. The Patient/Client Management Format: Writing History, Including the Review of Systems 12. The Patient/Client Management Format: Writing Systems Review and Tests and Measures 13. The SOAP Note: Stating the Problem 14. The SOAP Note: Writing Subjective (S), Including the Review of Systems 15. The SOAP Note: Writing Objective (O) IV. Documenting the Evaluation/Assessment (A) 16. Writing the Evaluation / Assessment (A) 17. Writing the Diagnosis (A: DIAGNOSIS) 18. Writing the Prognosis (A: PROGNOSIS) V. Documenting the Plan of Care (P) 19. Writing Expected Outcomes and Anticipated Goals 20. Documenting the Intervention Plan VI. Applications of Documentation Skills 21. Writing the Daily Visit Notes 22. The Medicare Therapy Cap, KX Modifiers, and Functional Limitations Reporting (G Codes) 23. Applications and Variations in Note Writing Appendices A. Summary of the Patient/Client Management Note Contents B. Summary of the SOAP Note Contents C. Summary of Contents of the Four Types of Notes D. Tips for Note Writing for Third Party Payers E. Review of Systems and Systems Review Forms

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Author Information

Associate Professor, Program in Physical Therapy, Saint Louis University, St. Louis, Missouri Adjunct Instructor in PT, St. Louis University; Physical Therapist at Select Medical at SSM St. Mary's Health Center & St. Louis University Hospital; St. Louis, MO Assistant Professor, Program in Physical Therapy, Saint Louis University, St. Louis, MO

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