Effective Documentation for Physical Therapy Professionals

Comprehensive textbook for the documentation course required in all Physical Therapy programs. Covers every aspect of documentation including reimbursement and billing, coding, legal issues, PT and PTA communication, as well as utilization review and quality assurance. Includes a bonus pocket book with sample documentation forms and checklists.

1. Introduction, Purpose and General Rules for Health Management (Medical Record Keeping)

2. Record Organization and General Principles

3. Application of Models for Organization and Guidelines for Content

4. Component Requirements

5. Coding and Documentation

6. Standardized Forms and Content

7. Legal Issues in the Medical Record

8. MDS Purpose and Components

9. Medicare and Non-Medicare Content Principles

10. Pediatric Documentation

11. The Electronic Medical Record or Computerized Patient Record

12. Utilization Review and Utilization Management

References

Appendices

Eric Shamus, PhD, PT, CSCS is an Assistant Professor of Physical Therapy and Track Coordinator of the Masters of Medical Science Sports Medicine Program in the College of Allied Health at Nova Southeastern University in Ft. Lauderdale, Florida. He is also an Assistant Professor of Osteopathic Medicine at Nova Southeastern.

Debra F. Stern, DBA, PT is an Assistant Professor of Physical Therapy, College of Allied Health at Nova Southeastern University.