リハビリテーションのためのドキュメンテーション:理学療法における臨床的意思決定ガイド(第4版)<br>Documentation for Rehabilitation - E-Book : Documentation for Rehabilitation - E-Book(4)

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リハビリテーションのためのドキュメンテーション:理学療法における臨床的意思決定ガイド(第4版)
Documentation for Rehabilitation - E-Book : Documentation for Rehabilitation - E-Book(4)

  • 言語:ENG
  • ISBN:9780323694308
  • eISBN:9780323694315

ファイル: /

Description

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.

Table of Contents

1. Disablement Models and the ICF Framework2. Essentials of Documentation3. Legal Aspects of Documentation4. Standardized Outcome Measures5. Payment Policy and Coding6. Electronic Medical Records7. Clinical Decision-Making and the Initial Evaluation Format8. Documenting Reason for Referral: Health Condition and Participation9. Documenting Activities10. Documenting Impairments in Body Structure and Function11. Documenting the Assessment: Summary and Diagnosis12. Developing and Documenting Effective Goals13. Documenting the Plan of Care14. Session Notes and Progress Notes Using a Modified SOAP Format15. Special Formats: Screening Evaluations, Discharge Summaries, Letters, and Patient Education Materials16. Documentation in Pediatrics