Documentation for Rehabilitation: A Guide to Clinical Decision Making
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...
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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. UNIQUE! Combination textbook/workbook format reinforces your understanding and tests your ability to apply concepts through practice exercises. UNIQUE! Systematic approach to documenting functional outcomes provides a practical framework for success in numerous practice settings. Case studies show you how to format goals through realistic client examples. Practice exercises provide valuable experience applying concepts to common clinical problems. Four NEW chapters address additional aspects of documentation that rehabilitation professionals will encounter in practice:Legal aspects of documentationDocumentation in pediatricsPayment policy and codingComputerized documentation
I. Theoretical Foundations & Documentation Essentials1. Disablement models, ICF Framework, and Clinical Decision Making2. Essentials of Documentation 3. Legal Aspects of Documentation - New4. Clinical Decision Making and the Initial Evaluation FormatII. Components of Physical Therapy Documentation5. Documenting History: Background Information and Health Condition6. Documenting History: Participation and Social History7. Documenting Activities8. Documenting Impairments in Body Structure and Function9. Documenting the Assessment: Summary and Diagnosis10. Documenting Goals11. Documenting the Plan of Care12. Daily Notes and Progress Notes using a Modified SOAP FormatIII. Additional Documentation Forms13. Specialized Documentation14. Documentation in Pediatrics - New15. Payment Policy and Coding - New16. Computerized Documentation - NewReferencesAppendix A. Guidelines for Physical Therapy Documentation Appendix B. Rehabilitation Abbreviations Appendix C. Answers to Exercises Appendix D. Sample Evaluation Forms
