Physical Therapy Documentation: From Examination to Outcome
Complete and accurate documentation is one of the most essential skills for a physical therapist to develop and use effectively. Necessary for both new and experienced practitioners, Physical Therapy Documentation: From Examination to Outcome will teach and explain physical therapy documentation from A to Z.\ Physical Therapy Documentation covers all of the fundamentals for prospective physical therapists preparing to work in the clinic or clinicians looking to refine and update their skills....
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Complete and accurate documentation is one of the most essential skills for a physical therapist to develop and use effectively. Necessary for both new and experienced practitioners, Physical Therapy Documentation: From Examination to Outcome will teach and explain physical therapy documentation from A to Z. Physical Therapy Documentation covers all of the fundamentals for prospective physical therapists preparing to work in the clinic or clinicians looking to refine and update their skills. Dr. Mia Erickson along with Rebecca McKnight and Dr. Ralph Utzman discuss documentation issues while providing a framework for the actual documentation format. In addition, Physical Therapy Documentation draws comparisons between the familiar, traditional documentation formats and contemporary models to provide a foundation for clinicians and students to use when documenting in any practice setting. Practice exercises and case studies are provided throughout the text demonstrating note-writing across the continuum of care. This text will allow the student or clinician to produce quality documentation consistent with current standards of practice. The Guide to Physical Therapist Practice is referenced throughout the text as the model for patient/client management. What’s Inside: • Disablement models • Reasons for documentation • Documentation formats • Documentation and patient-client management • Discussion of reimbursement issues • Discussion of legal issues • Practical tips for note writing Throughout Physical Therapy Documentation, The World Health Organization’s International Classification of Functioning, Disability, and Health (ICF) language is used. The text is also correlated with the Nagi Model, which is well-known to most physical therapists, to help provide a bridge from the older model to the contemporary model. Physical Therapy Documentation provides physical therapy students, educators, and clinicians with a valuable reference tool for documentation within contemporary physical therapy practice.
Ch. 1 Overview of Disablement Mia Erickson Erickson, Mia 1Ch. 2 Reasons for Documenting in Physical Therapy Mia Erickson Erickson, Mia Rebecca McKnight McKnight, Rebecca 17Ch. 3 Documenting Patient/Client Management Mia Erickson Erickson, Mia Rebecca McKnight McKnight, Rebecca 27Ch. 4 Documentation Formats Mia Erickson Erickson, Mia 43Ch. 5 Rules for Writing in Medical Records Mia Erickson Erickson, Mia 65Ch. 6 Recording Subjective Information Rebecca McKnight McKnight, Rebecca 79Ch. 7 Recording Objective Information Rebecca McKnight McKnight, Rebecca 93Ch. 8 Writing the Assessment and the Plan Rebecca McKnight McKnight, Rebecca 109Ch. 9 Interim and Discharge Notes Rebecca McKnight McKnight, Rebecca 125Ch. 10 Examining Your Patients' Outcomes Mia Erickson Erickson, Mia 143Ch. 11 Legal, Regulatory and Policy Issues in Documentation Ralph Utzman Utzman, Ralph 155Ch. 12 Documentation and Reimbursement Ralph Utzman Utzman, Ralph 163App. A APTA Guidelines for Physical Therapy Documentation of Patient/Client Management 172App. B Abbreviations and Symbols 180App. C Sample Forms 186App. D Preferred Practice Patterns 193Glossary 197Index 205
