Documentation for Physical Therapist Assistants

by Bircher, Wendy D.

• ISBN13: 9780803661141
• ISBN10: 0803661142
• Edition: 5th
• Format: Paperback
• Copyright: 2017-09-29
• Publisher: F.A. Davis Company

Summary

Build your documentation skills—and your confidence. Step by step, this text/workbook introduces you to the importance of documentation; shows you how to develop and write a proper and defensible note; and prepares you to meet the technological challenges you’ll encounter in practice.

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

I. Why Is Documentation Important?
1. Introduction to Documentation
2. The World Health Organization and the International Classification of Functioning, Disability and Health
3. Demystifying the ICD-10 Coding System
4. Reimbursement Issues Related to Documentation
5. Documentation Content and Organization
6.Physical Therapy Patient Management and Documentation Responsibilities

II. How Do SOAP Notes Ensure Good Patient Care?
7. How Does Documentation Relate to Patient Issues?
8. Your Documentation Related to Legal and Ethical Issues

III. Steps to Documentation
9.Introduction to the SOAP Note
10.What Are Subjective Data and Why Are They Important?
11.What Are Objective Data and Why Are They Important?
12. What Are Assessment Data and Why Are They Important?
13. What Is the Plan and Why Is It Important?

IV. Testing What You Know
14.Putting the Pieces Together
15.Do You Know Enough?

Bibliography
Glossary
Appendices
A. Abbreviations
B. Defensible Documentation Elements and Documentation Review Sample Checklist
C. SOAP Note Rubric
D. Documenting Interventions