Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy

ISBN-13: 9780323694308 / Angielski / Miękka / 2024 / 304 str.

FAPTA (Professor and Associate DeanDivision PT EdD James

Spis treści

Section 1: Key Aspects of Clinical Documentation
1. Disablement Models and the ICF Framework
2. Essentials of Documentation
3. Legal Aspects of Documentation
4. Standardized Outcome Measures
5. Payment Policy and Coding
6. Electronic Medical Record
Section 2: Documenting the Initial Evaluation and Beyond: A Case-Based Guide
7. Clinical Decision Making and the Initial Evaluation Format
8. Documenting Reason for Referral: Health Condition and Participation
9. Documenting Activities
10. NEW! Movement Analysis - Linking Activities and Impairments
11. Documenting Impairments in Body Structure and Function
12. Documenting the Assessment: Summary and Diagnosis
13. Developing and Documenting Effective Goals
14. Documenting the Plan of Care
15. Session Notes and Progress Notes Using a Modified SOAP Format
16. Special Formats: Screening Evaluations, Discharge Summaries, Letters, and Patient Education Materials
17. Documentation in Pediatrics
References
Appendix A: Guidelines for Physical Therapy Documentation
Appendix B: Rehabilitation Abbreviations
Appendix C: Answers to Exercises
Appendix D: Documentation Review Sample Checklist
Appendix E: Sample Range of Motion and Strength Assessment Form