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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, 4th Edition demonstrates how to accurately document treatment progress and patient outcomes using a framework for clinical reasoning based on the International Classification for Functioning, Disability, and Health (ICF) model adopted by the American Physical Therapy Association (APTA). The documentation guidelines in this practical resource are easily adaptable to different practice settings and patient populations in physical therapy and physical therapy assisting. Realistic examples and practice exercises reinforce the understanding and application of concepts, improving skills in both documentation and clinical reasoning.

  • Workbook/textbook format with examples and exercises in each chapter helps reinforce understanding of concepts.
  • Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, nursing homes, pediatrics, school, and community settings.
  • Case examples for a multitude of documentation types include initial evaluations, progress notes, daily notes, letters to insurance companies, Medicare documentation, and documentation in specialized settings.
  • NEW! Movement Analysis – Linking Activities and Impairments content addresses issues related to diagnosis.
  • NEW! An eBook version, included with print purchase, provides access to all the text, figures and references, with the ability to search, customize content, make notes and highlights, and have content read aloud.
  • Updated case examples provide clinical context for patient documentation.
  • Revised content, including updated terminology from the latest updates to the Guide to Physical Therapist Practice, provides the most current information needed to be an effective practitioner.
  • Updated references ensure content is current and applicable for today’s practice.

1. Cover image - p. i 2. Title page - p. ii 3. Table of Contents - p. iii 4. Activate your eBook today! - p. iii 5. Title page - p. IFC1 6. Copyright - p. IFC1 7. Contributors - p. iv 8. Foreword - p. iv 9. Preface - p. vii 10. Acknowledgments - p. ix 11. Contents - p. xi 12. List of Illustrations - p. xi 13. List of Tables - p. xi 14. Section I: Key Aspects of Clinical Documentation - p. xi 15. Chapter 1: Disablement Models and the ICF Framework - p. xi 16. Chapter 2: Essentials of Documentation - p. 7 17. Chapter 3: Legal Aspects of Documentation - p. 20 18. Chapter 4: Standardized Outcome Measures - p. 26 19. Chapter 5: Payment Policy and Coding - p. 32 20. Chapter 6: Electronic Medical Records - p. 49 21. Section II: Documenting the Initial Evaluation and Beyond: A Case-Based Guide - p. 55 22. Chapter 7: Clinical Decision-Making and the Initial Evaluation Format - p. 55 23. Chapter 8: Documenting Reason for Referral: Health Condition and Participation - p. 71 24. Chapter 9: Documenting Activities - p. 88 25. Chapter 10: Documenting Impairments in Body Structure and Function - p. 104 26. Chapter 11: Documenting the Assessment: Summary and Diagnosis - p. 115 27. Chapter 12: Developing and Documenting Effective Goals - p. 124 28. Chapter 13: Documenting the Plan of Care - p. 136 29. Chapter 14: Session Notes and Progress Notes Using a Modified SOAP Format - p. 143 30. Chapter 15: Special Formats: Screening Evaluations, Discharge Summaries, Letters, and Patient Education Materials - p. 157 31. Chapter 16: Documentation in Pediatrics - p. 170 32. References - p. 184 33. American Physical Therapy Association Position on Documentation - p. 184 34. Rehabilitation Abbreviations - p. 195 35. Answers to Exercises - p. 204 36. Documentation Review Sample Checklist - p. 217 37. Sample Range of Motion and Strength Assessment Form - p. 221 38. Index - p. 223

Descripcion
Descripción

Better patient management starts with better documentation! Documentation for Rehabilitation, 4th Edition demonstrates how to accurately document treatment progress and patient outcomes using a framework for clinical reasoning based on the International Classification for Functioning, Disability, and Health (ICF) model adopted by the American Physical Therapy Association (APTA). The documentation guidelines in this practical resource are easily adaptable to different practice settings and patient populations in physical therapy and physical therapy assisting. Realistic examples and practice exercises reinforce the understanding and application of concepts, improving skills in both documentation and clinical reasoning.

  • Workbook/textbook format with examples and exercises in each chapter helps reinforce understanding of concepts.
  • Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, nursing homes, pediatrics, school, and community settings.
  • Case examples for a multitude of documentation types include initial evaluations, progress notes, daily notes, letters to insurance companies, Medicare documentation, and documentation in specialized settings.
  • NEW! Movement Analysis – Linking Activities and Impairments content addresses issues related to diagnosis.
  • NEW! An eBook version, included with print purchase, provides access to all the text, figures and references, with the ability to search, customize content, make notes and highlights, and have content read aloud.
  • Updated case examples provide clinical context for patient documentation.
  • Revised content, including updated terminology from the latest updates to the Guide to Physical Therapist Practice, provides the most current information needed to be an effective practitioner.
  • Updated references ensure content is current and applicable for today’s practice.

1. Cover image - p. i 2. Title page - p. ii 3. Table of Contents - p. iii 4. Activate your eBook today! - p. iii 5. Title page - p. IFC1 6. Copyright - p. IFC1 7. Contributors - p. iv 8. Foreword - p. iv 9. Preface - p. vii 10. Acknowledgments - p. ix 11. Contents - p. xi 12. List of Illustrations - p. xi 13. List of Tables - p. xi 14. Section I: Key Aspects of Clinical Documentation - p. xi 15. Chapter 1: Disablement Models and the ICF Framework - p. xi 16. Chapter 2: Essentials of Documentation - p. 7 17. Chapter 3: Legal Aspects of Documentation - p. 20 18. Chapter 4: Standardized Outcome Measures - p. 26 19. Chapter 5: Payment Policy and Coding - p. 32 20. Chapter 6: Electronic Medical Records - p. 49 21. Section II: Documenting the Initial Evaluation and Beyond: A Case-Based Guide - p. 55 22. Chapter 7: Clinical Decision-Making and the Initial Evaluation Format - p. 55 23. Chapter 8: Documenting Reason for Referral: Health Condition and Participation - p. 71 24. Chapter 9: Documenting Activities - p. 88 25. Chapter 10: Documenting Impairments in Body Structure and Function - p. 104 26. Chapter 11: Documenting the Assessment: Summary and Diagnosis - p. 115 27. Chapter 12: Developing and Documenting Effective Goals - p. 124 28. Chapter 13: Documenting the Plan of Care - p. 136 29. Chapter 14: Session Notes and Progress Notes Using a Modified SOAP Format - p. 143 30. Chapter 15: Special Formats: Screening Evaluations, Discharge Summaries, Letters, and Patient Education Materials - p. 157 31. Chapter 16: Documentation in Pediatrics - p. 170 32. References - p. 184 33. American Physical Therapy Association Position on Documentation - p. 184 34. Rehabilitation Abbreviations - p. 195 35. Answers to Exercises - p. 204 36. Documentation Review Sample Checklist - p. 217 37. Sample Range of Motion and Strength Assessment Form - p. 221 38. Index - p. 223

Indice
Autores
Muestra
Ficha Técnica