Documentation Basics for the Physical Therapist Assistant

by Erickson, Mia; McKnight, Becky

• ISBN13: 9781630914028
• ISBN10: 1630914029
• eBook ISBN(s): 9781040142127
• Additional ISBN(s): 9781617110085
• Edition: 3rd
• Format: Paperback
• Copyright: 2017-12-15
• Publisher: Slack Incorporated
• More Book Details

Summary

Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. The new Third Edition of Documentation Basics for the Physical Therapist Assistant continues the path of teaching the student and clinician documentation from A to Z.
 
Mia Erickson and Rebecca McKnight have updated this Third Edition to reflect changes in the ever-evolving profession. Newly addressed are the changes in documentation requirements for major payers, changes in the disablement models used, and the increasingly common use of electronic documentation in the physical therapy profession.
 
Features inside the Third Edition:

• Readers are encouraged to think about disablement and disablement concepts when writing notes
• How to document impairments in body structure and function but more importantly activity limitations and participation restriction
• Descriptions of the differences in documentation methods using a computer vs paper chart
• Evidence tied to benefits and challenges of computerized documentation
• Documenting the rationale for treatment and the unique skills of the physical therapist assistant in patient management

 
New inside the Third Edition:

• Incorporation of the International Classification of Functioning, Disability, and Health  disablement model
• Chapter on electronic documentation
• Screenshot examples of the popular WebPT® electronic medical record platform
• Updated chapters on reimbursement and legal issues
• Additional examples for student practice included in each chapter

 
Instructors in educational settings can visit www.efacultylounge.com for additional material to be used for teaching in the classroom.
 
Documentation Basics for the Physical Therapist Assistant, Third Edition is the perfect guide for all physical therapist assistant students and clinicians who want to update and refine their knowledge and skills in documentation.
 
 

Author Biography

Mia L. Erickson, PT, EdD, CHT, ATC, is a faculty member in the Physical Therapy Department at Midwestern University in Glendale, AZ. Mia earned a bachelor’s degree from West Virginia University in secondary education in 1994 and a master of science degree in physical therapy from the University of Indianapolis in 1996. Mia earned a doctoral degree in education from West Virginia University with an emphasis on curriculum and instruction in 2002. Her clinical practice is in the area of hand and upper-extremity rehabilitation.

Rebecca McKnight, PT, MS, received her bachelor of science degree in physical therapy from St. Louis University in 1992 and her postprofessional master of science degree from Rocky Mountain University of Health Professions in 1999. She taught at Ozarks Technical Community College for 14 years, serving as Program Director for 9 of those years. Rebecca is an active member of the American Physical Therapy Association and is a former chair of the Physical Therapist Assistant Educators Special Interest Group of the education section. Rebecca has spoken at many national meetings on physical therapist assistant curriculum design and programmatic assessment. She is the 2009 recipient of the F.A. Davis Award for Outstanding Physical Therapist Assistant Educator. Rebecca has been providing educational consultation in the areas of curriculum design, development, and assessment for physical therapist assistant programs nationwide since 2007.
 

Table of Contents

About the Authors

Preface

 

Chapter 1            Disablement and Physical Therapy Documentation

Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 2            The Physical Therapy Episode of Care

Rebecca McKnight, PT, MS

Chapter 3            Reasons for Documenting

Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 4            Documentation Formats

Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 5            Electronic Medical Record

Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 6            Basic Guidelines for Documentation

Rebecca McKnight, PT, MS and Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 7            Interpreting the Physical Therapist Initial Evaluation

Rebecca McKnight, PT, MS

Chapter 8            Writing the Subjective Section

Rebecca McKnight, PT, MS

Chapter 9            Writing the Objective Section

Rebecca McKnight, PT, MS

Chapter 10          Writing the Assessment and Plan Sections

Rebecca McKnight, PT, MS

Chapter 11          Payment Basics

Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 12          Legal and Ethical Considerations for Physical Therapy Documentation

Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 13          Documentation Across the Curriculum

Mia L. Erickson, PT, EdD, CHT, ATC

                                Traumatic Brain Injury

Tracy Rice, PT, MPH, NCS

                                Spinal Cord Injury

Tracy Rice, PT, MPH, NCS

Appendix: Abbreviations and Symbols

Index