Effective Documentation for Physical Therapy Professionals, Second Edition

A comprehensive textbook covering every aspect of the documentation process required in physical therapy practice Effective Documentation for Physical Therapy Professionalsgives physical therapy students a solid understanding of the professional guidelines, codes, and methodology needed to provide expert documentation within their field. Filled with sample forms and documentation content, the book covers all major aspects of the subject, including reimbursement and billing, coding, legalities, PT and PTA communication, and quality assurance.Features Incorporates current APTA terminology and all pertinent professional association regulations Includes numerous sample forms and documents Contains a wealth of examples and exercises to provide students with a working knowledge of documentationThe content you need to understand every aspect of the documentation process: Chapter 1. Introduction, Purpose and General Rules for Health Management (Medical Record Keeping) Chapter 2. Record Organization and General Principles Chapter 3. Application of Models for Organization and Guidelines for Content Chapter 4. Component Requirements Chapter 5. Coding and Documentation Chapter 6. Standardized Forms and Content Chapter 7. Legal Issues in the Medical Record Chapter 8. MDS Purpose and Components Chapter 9. Medicare and Non-Medicare Content Principles Chapter 10. Pediatric Documentation Chapter 11. The Electronic Medical Record or Computerized Patient Record Chapter 12. Utilization Review and Utilization Management Appendix A: Abbreviations Appendix B: CMS 700 Form Appendix C: CMS FOrms 1450 and 1500 with Instructions Appendix D: ICD-9 Code Terms Appendix E: APTA Guidelines for Physical Therapy Appendix F: Goal Writing Exercise Appendix G: Note Writing Exercise Appendix H: Documentation Content Exercise Appendix I: Physical Therapy Note Examples

Author Profiles
Eric Shamus, MS, PT, CSCS has taught national and international continuing education courses on Orthopedics and Sports Medicine, with a focus on documentation and reimbursement. He is presently a professor at Nova Southeastern University, and works at an outpatient orthopedic facility in Fort Lauderdale.

Debra F Stern, PT, MSM, DBA, is an Associate Professor at Nova Southeastern University in Fort Lauderdale, FL. She serves as a clinical instructor with a focus on geriatrics, neuromuscular disorders, and also coordinates service learning experiences for the school's PT department. She received her BS in Physical Therapy from SUNY Buffalo, her MSM from Rollins College, and her DBAS at Nova Southeastern.

Chapter 1. Introduction, Background, Purpose and General Rules for Health Information Management (Medical Record Keeping)Chapter 2. Record Organization and General PrinciplesChapter 3. Application of Models for Organization and Guidelines for ContentChapter 4. Content Standardization/Component RequirementsChapter 5. Coding and DocumentationChapter 6. Home Health DocumentationChapter 7. Legal Issues in the Medical RecordChapter 8. MDS Purpose and ComponentsChapter 9. Medicare and Non-Medicare Content PrinciplesChapter 10. Pediatric DocumentationChapter 11. The Electronic Medical RecordChapter 12. Utilization Review and Utilization ManagementAppendix A: AbbreviationsAppendix B: CMS 700 Form and CS-1786 HIPPA Disclosure FormAppendix C: CMS Forms 1450 and 1500 with InstructionsAppendix D: ICD-9 Code TermsAppendix E: APTA Guidelines for Physical Therapy Documentation and Guidelines for Group CodingAppendix F: Goal Writing ExerciseAppendix G: Note Writing ExerciseAppendix H: Documentation Content ExerciseAppendix I: Documentation Content Examples