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Ensure confident clinical decisions and maximum reimbursement in a variety of practice settings such as acute care, outpatient, home care, and nursing homes with the only systematic approach to documentation for rehabilitation professionals! Revised and expanded, this hands-on textbook/workbook provides a unique framework for maintaining evidence of treatment progress and patient outcomes with a clear, logical progression. Extensive examples and exercises in each chapter reinforce concepts and encourage you to apply what you've learned to realistic practice scenarios. UNIQUE! Combination textbook/workbook format reinforces your understanding and tests your ability to apply concepts through practice exercises.UNIQUE! Systematic approach to documenting functional outcomes provides a practical framework for success in numerous practice settings.Case studies show you how to format goals through realistic client examples.Practice exercises provide valuable experience applying concepts to common clinical problems.Four NEW chapters address additional aspects of documentation that rehabilitation professionals will encounter in practice:Legal aspects of documentationDocumentation in pediatricsPayment policy and codingComputerized documentation
Table of Contents
|Theoretical Foundations & Documentation Essentials|
|Disablement models, ICF Framework, and Clinical Decision Making|
|Essentials of Documentation|
|Legal Aspects of Documentation - New|
|Clinical Decision Making and the Initial Evaluation Format|
|Components of Physical Therapy Documentation|
|Documenting History: Background Information and Health Condition|
|Documenting History: Participation and Social History|
|Documenting Impairments in Body Structure and Function|
|Documenting the Assessment: Summary and Diagnosis|
|Documenting the Plan of Care|
|Daily Notes and Progress Notes using a Modified SOAP Format|
|Additional Documentation Forms|
|Documentation in Pediatrics - New|
|Payment Policy and Coding - New|
|Computerized Documentation - New|
|Guidelines for Physical Therapy Documentation|
|Answers to Exercises|
|Sample Evaluation Forms|
|Table of Contents provided by Publisher. All Rights Reserved.|