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Documentation Basics : A Guide for the Physical Therapist Assistant

by ;
Edition:
1st
ISBN13:

9781556426735

ISBN10:
1556426739
Format:
Paperback
Pub. Date:
2/24/2005
Publisher(s):
Slack Incorporated

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  • Documentation Basics A Guide for the Physical Therapist Assistant
    Documentation Basics A Guide for the Physical Therapist Assistant





Summary

Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. Necessary for both students and clinicians,Documentation Basics: A Guide for the Physical Therapist Assistantwill teach and explain physical therapy documentation from A to Z.Documentation Basics: A Guide for the Physical Therapist Assistantcovers all of the fundamentals for prospective physical therapist assistants preparing to work in the clinic or clinicians looking to refine and update their skills. Mia Erickson and Becky McKnight have also integrated throughout the text theAPTA's Guide to PT Practiceto provide up-to-date information on the topics integral for proper documentation. What's Inside: Overview of documentation Types of documentation Guidelines for documenting Overview of the PTA's role in patient/client management, from the patient's point of entry to discharge How to write progress notes How to use the PT's initial examinations, evaluations, and plan of care when writing progress notes Legal matters related to documentation Reimbursement basics and documentation requirementsThe text also contains a section titled "SOAP Notes Across the Curriculum," or SNAC. This section provides sample scenarios and practice opportunities for PTA students that can be used in a variety of courses throughout a PTA program. These include: Goniometry Range of motion exercises Wound care Stroke Spinal cord injury AmputationEnter the physical therapy profession confidently withDocumentation Basics: A Guide for the Physical Therapist Assistantby your side.

Author Biography

Mia L. Erickson, PT, EdD, ATC, CHT
Dr. Erickson is the former Program Director of the Physical Therapist Assistant Program at Allegany College of Maryland. Currently she is an Assistant Professor and Co-Academic Coordinator of Clinical Education at West Virginia University. She has a Bachelor’s Degree in Secondary Education and Athletic Training from West Virginia University and a Master of Science Degree in Physical Therapy from the University of Indianapolis. She completed her doctoral work at West Virginia University with emphasis in curriculum and instruction. She maintains clinical practice in the areas of outpatient orthopedics and hand rehabilitation.
Becky McKnight, PT, MS
Ms. McKnight is currently the Program Coordinator of the Physical Therapist Assistant Program at Ozarks Technical Community College. She received a Bachelor’s Degree in Physical Therapy from St. Louis University and a post-professional Master’s Degree in Physical Therapy from Rocky Mountain University of Health Professions. She has also been an Academic Coordinator of Clinical Education at Ozarks Technical Community College. She maintains clinical practice and teaching responsibilities in the areas of neurology and geriatrics.

Table of Contents

Acknowledgments ix
About the Authors xi
Preface xiii
Physical Therapy and Disablement
1(10)
Mia L. Erickson
Chapter Objectives
1(1)
Defining Health and Disability
1(3)
International Classification of Functioning, Disability, and Health
2(1)
The Nagi Framework
2(2)
Physical Therapy and Disablement: Putting it all Together
4(1)
Disablement and Documentation
4(2)
Review Questions
6(2)
Application Exercises
8(3)
Reasons for Documenting
11(10)
Mia L. Erickson
Chapter Objectives
11(1)
Overview
11(1)
Reasons for Documenting
12(3)
Record Patient Data
12(1)
Demonstrate the Clinical Decision-Making Process
13(1)
Provide Proof of Medical Necessity
13(1)
Provide Proof of Skilled Care
14(1)
The Event of Legal Action
14(1)
Review Questions
15(1)
Application Exercises
16(5)
Documentation Formats
21(12)
Mia L. Erickson
Chapter Objectives
21(1)
Narrative
21(1)
Problem-Oriented Medical Record
22(1)
SOAP Notes
23(2)
Functional Outcomes Reporting (FOR)
25(1)
Templates and Fill-in Forms
26(1)
Computerized Documentation
27(1)
Review Questions
28(2)
Application Exercises
30(3)
The Physical Therapy Process
33(18)
Becky McKnight
Chapter Objectives
33(1)
Introduction
33(1)
The Physical Therapy Process
34(2)
Patient Point of Entry
34(1)
The Patient/Client Management Model
34(2)
Physical Therapist and Physical Therapist Assistant Roles
36(1)
Coordination, Communication, and Documentation
37(1)
Utilizing the Physical Therapy Documentation
37(5)
SOAP Initial Evaluative Note
38(2)
How to Use the Initial Evaluative Note
40(2)
Review Questions
42(1)
Application Exercises
43(8)
Documentation Practice
51(24)
Becky McKnight
Mia L. Erickson
Chapter Objectives
51(1)
Documentation in Physical Therapy
51(1)
Basic Principles
52(1)
Documenting Patient Care
53(12)
Informed Consent
55(1)
Problem (P)
55(1)
Subjective (S)
55(1)
Objective (O)
56(5)
Assessment (A)
61(2)
Plan (P)
63(2)
Review Questions
65(1)
Application Exercises
66(9)
Reimbursement Basics
75(10)
Mia L. Erickson
Chapter Objectives
75(1)
What is Reimbursement?
75(1)
Types of Insurance
75(4)
Social Insurance
76(2)
Managed Care
78(1)
Casualty Insurance
79(1)
Indemnity Insurance
79(1)
Documentation and Reimbursement
79(2)
Review Questions
81(2)
Application Exercises
83(2)
Legal and Ethical Considerations for Physical Therapy Documentation
85(8)
Mia L. Erickson
Chapter Objectives
85(1)
Introduction
85(1)
Patient Privacy and Confidentiality
85(2)
The Privacy Act of 1974 (5 U.S.C. § 552a)
85(1)
Health Insurance Portability and Accountability Act
86(1)
Privacy and State Law
86(1)
Privacy Recommendations and Computerized Documentation
86(1)
Privacy and Ethics
86(1)
Fraud and Abuse
87(1)
Risk Management
87(1)
Establishing Documentation Requirements
87(2)
Federal Agencies
87(1)
State Practice Acts
88(1)
American Physical Therapy Association
88(1)
Review Questions
89(4)
SOAP Notes Across the Curriculum
93(24)
Goniometry
94(1)
Strength Assessment
95(1)
Range of Motion Exercises
96(1)
Transfers
97(2)
Tilt Table
99(1)
Wheelchairs
100(1)
Gait Training
101(2)
Wound Care
103(1)
Chronic Obstructive Pulmonary Disease/Vital Signs
104(1)
Traumatic Brain Injury
105(1)
Cerebrovascular Accident
106(2)
Lower Extremity Amputation/Prosthetic Devices
108(3)
Musculoskeletal Trauma
111(2)
Pediatrics/Orthotic Devices
113(4)
Glossary 117(6)
Appendix A: Abbreviations and Symbols 123(8)
Appendix B: Sample Forms and Templates 131(14)
Jeff Erickson
References 145(6)
Index 151


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