Description
- NEW Standardized Outcome Measures chapter leads to better care and patient management by helping you select the right outcome measures for use in evaluations, re-evaluations, and discharge summaries.- UPDATED content is based on data from current research, federal policies and APTA guidelines, including incorporation of new terminology from the Guide to Physical Therapist 3.0 and ICD-10 coding.- EXPANDED number of case examples covers an even broader range of clinical practice areas.
Table of Contents
I: THEORETICAL FOUNDATIONS1. Disablement Models, ICF Framework and Clinical Decision Making2. Essentials of Documentation3. Legal Aspects of Documentation 4. Standardized Outcome Measures NEW!5. Payment Policy and Coding6 Electronic Medical RecordsII: COMPONENTS OF PHYSICAL THERAPY DOCUMENTATION7. Clinical Decision Making and the Initial Evaluation Format 8. Documenting Reason for Referral: Health Condition and Participation9. Documenting Activities10. Documenting Impairments11. Document the Assessment: Summary and Diagnosis 12. Developing and Documenting Effective Goals13. Documenting the Plan of Care14. Documenting Session Notes and Progress Notes Using a Modified SOAP Note Format15. Special Formats: Documenting Screenings, Discharge Summaries, Letters and Patient Education Materials16. Documentation in Pediatrics ReferencesAppendix A: Guidelines: Physical Therapy Documentation of Patient/Client ManagementAppendix B: Rehabilitation AbbreviationsAppendix C: Answers to ExercisesAppendix D: Documentation Review Sample Checklist Appendix E: Strength and Range of Motion Forms
