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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. Copyright - p. iv 5. Contributors - p. v 6. Foreword - p. vii 7. Preface - p. ix 8. Acknowledgments - p. xi 9. Section I: Key Aspects of Clinical Documentation - p. 1 10. 1. Disablement Models and the ICF Framework - p. 1a 11. 2. Essentials of Documentation - p. 9 12. 3. Legal Aspects of Documentation - p. 21 13. 4. Standardized Outcome Measures - p. 27 14. 5. Payment Policy and Coding - p. 33 15. 6. Electronic Medical Records - p. 51 16. Section II: Documenting the Initial Evaluation and Beyond: A Case-Based Guide - p. 56 17. 7. Clinical Decision-Making and the Initial Evaluation Format - p. 57 18. 8. Documenting Reason for Referral: Health Condition and Participation - p. 73 19. 9. Documenting Activities - p. 91 20. 10. Documenting Impairments in Body Structure and Function - p. 105 21. 11. Documenting the Assessment: Summary and Diagnosis - p. 117 22. 12. Developing and Documenting Effective Goals - p. 125 23. 13. Documenting the Plan of Care - p. 137 24. 14. Session Notes and Progress Notes Using a Modified SOAP Format - p. 145 25. 15. Special Formats: Screening Evaluations, Discharge Summaries, Letters, and Patient Education Materials - p. 159 26. 16. Documentation in Pediatrics - p. 171 27. References - p. 185 28. Appendix A. American Physical Therapy Association Position on Documentation - p. 191 29. Appendix B. Rehabilitation Abbreviations - p. 198 30. Appendix C. Answers to Exercises - p. 205 31. Appendix D. Documentation Review Sample Checklist - p. 219 32. Appendix E. Sample Range of Motion and Strength Assessment Form - p. 223 33. Index - p. 225

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. Copyright - p. iv 5. Contributors - p. v 6. Foreword - p. vii 7. Preface - p. ix 8. Acknowledgments - p. xi 9. Section I: Key Aspects of Clinical Documentation - p. 1 10. 1. Disablement Models and the ICF Framework - p. 1a 11. 2. Essentials of Documentation - p. 9 12. 3. Legal Aspects of Documentation - p. 21 13. 4. Standardized Outcome Measures - p. 27 14. 5. Payment Policy and Coding - p. 33 15. 6. Electronic Medical Records - p. 51 16. Section II: Documenting the Initial Evaluation and Beyond: A Case-Based Guide - p. 56 17. 7. Clinical Decision-Making and the Initial Evaluation Format - p. 57 18. 8. Documenting Reason for Referral: Health Condition and Participation - p. 73 19. 9. Documenting Activities - p. 91 20. 10. Documenting Impairments in Body Structure and Function - p. 105 21. 11. Documenting the Assessment: Summary and Diagnosis - p. 117 22. 12. Developing and Documenting Effective Goals - p. 125 23. 13. Documenting the Plan of Care - p. 137 24. 14. Session Notes and Progress Notes Using a Modified SOAP Format - p. 145 25. 15. Special Formats: Screening Evaluations, Discharge Summaries, Letters, and Patient Education Materials - p. 159 26. 16. Documentation in Pediatrics - p. 171 27. References - p. 185 28. Appendix A. American Physical Therapy Association Position on Documentation - p. 191 29. Appendix B. Rehabilitation Abbreviations - p. 198 30. Appendix C. Answers to Exercises - p. 205 31. Appendix D. Documentation Review Sample Checklist - p. 219 32. Appendix E. Sample Range of Motion and Strength Assessment Form - p. 223 33. Index - p. 225

Indice
Autores
Muestra
Ficha Técnica