Documentation for the Physical Therapist Assistant

by Bircher, Wendy D.

• ISBN13: 9780803626744
• ISBN10: 0803626746
• Edition: 4th
• Format: Paperback
• Copyright: 2013-01-18
• Publisher: F A Davis Co

Summary

Build your documentation skills and your confidence. Step by step, this text/workbook introduces you to the importance of documentation and shows you how to develop and write a proper and defensible note.You ll learn how to provide the proper documentation to assure all forms of reimbursement (including third party) for your services. You ll also explore issues of patient confidentiality, HIPAA requirements, and the ever-increasing demands of legal and ethical practice in a litigious society.

Table of Contents

Why is Documentation Important? Introduction to Documentation? The World Health Organization and the International Classification of Functioning, Disability and Health Reimbursement Issues Related to Documentation Documentation Content and Organization Physical Therapy Patient Management and Documentation Responsibilities Steps to Documentation Introduction to the SOAP Note What Is Subjective Data and Why Is It Important? What Is Objective Data and Why Is It Important? What Is Assessment Data and Why Is It Important? What Is the Plan and Why Is It Important? Putting the Pieces of the Puzzle Together How Do SOAP Notes Ensure Good Patient Care? How Does Documentation Relate to Patient Issues? Your Documentation Related to Legal and Ethical Issues Testing What You Know Do You Know Enough? Bibliography Glossary Appendices Appendix A: Abbreviations (from last edition) Appendix B: Defensible Documentation Elements and Review Documentation Checklist (New) Appendix C: SOAP Note Rubric (New) Appendix D: Documenting Interventions (Appendix B from last edition) Index