Ensure confident clinical decisions and maximum reimbursement in a variety of practice settings such as acute care, outpatient, home care, and nursing homes with the only systematic approach to documentation for rehabilitation professionals! Revised and expanded, this hands-on textbook/workbook provides a unique framework for maintaining evidence of treatment progress and patient outcomes with a clear, logical progression. Extensive examples and exercises in each chapter reinforce concepts and encourage you to apply what you?ve learned to realistic practice scenarios.
II. Components of Physical Therapy Documentation 5. Documenting History: Background Information and Health Condition 6. Documenting History: Participation and Social History 7. Documenting Activities 8. Documenting Impairments in Body Structure and Function 9. Documenting the Assessment: Summary and Diagnosis 10. Documenting Goals 11. Documenting the Plan of Care 12. Daily Notes and Progress Notes using a Modified SOAP Format
III. Additional Documentation Forms 13. Specialized Documentation 14. Documentation in Pediatrics - New 15. Payment Policy and Coding - New 16. Computerized Documentation - New
References Appendix A. Guidelines for Physical Therapy Documentation Appendix B. Rehabilitation Abbreviations Appendix C. Answers to Exercises Appendix D. Sample Evaluation Forms