Functional Outcomes Documentation for Rehabilitation

by Quinn & Gordon

• ISBN13: 9780721689470
• ISBN10: 0721689477
• Format: Paperback
• Copyright: 2003-01-31
• Publisher: Saunders

Summary

This hands-on textbook/workbook teaches readers how to document functional outcomes in a clear, logical progression. Extensive examples and exercises in each chapter highlight the essential points of functional outcomes documentation, designed to help improve client function and reduce disability as well as provide evidence of functional progress for insurance payment and reimbursement. Provides both theoretical foundations and a practical approach to functional outcomes documentation. Presents a top-down perspective on rehabilitation, based on the Nagi disablement model. Numerous examples and exercises in every chapter allow readers to put documentation skills into practice as they learn essential theoretical concepts. An overview of key legal issues related to physical therapy documentation is provided. Functional outcomes documentation in a variety of settings is covered, including acute care, rehabilitation, outpatient, home care, nursing homes, pediatrics, school settings, and group homes. Examples illustrate a range of impairments featuring different client groups that challenge students to consider real-life scenarios.

Table of Contents

I THEORETICAL FOUNDATIONS
Introduction	3	(10)
Essentials of Documentation	13	(12)
Overview of Functional Outcomes Approach to Documentation: The Initial Evaluation Format	25	(14)
II COMPONENTS OF PHYSICAL THERAPY DOCUMENTATION
Documenting Reason for Referral: Background Information, Medical Diagnosis, and History	39	(10)
Documenting Reason for Referral: Disability and Social History	49	(14)
Documenting Functional Status: A Skill-Based Model	63	(16)
Documenting Impairments	79	(10)
Documenting the Assessment: The Physical Therapy Diagnosis	89	(10)
Documenting Goals	99	(12)
Documenting the Intervention Plan	111	(10)
III ADDITIONAL DOCUMENTATION FORMATS
Documenting Daily Notes and Progress Notes: Elements of the SOAP Record	121	(12)
Specialized Documentation	133	(14)
Automating Physical Therapy Documentation	147	(10)
Janet Herbold
REFERENCES	157	(2)
APPENDICES
A Guidelines for Physical Therapy Documentation	159	(6)
B Rehabilitation Abbreviations	165	(8)
C Answers to Exercises	173	(22)
D Sample Evaluation Forms	195