Functional Outcomes Documentation for Rehabilitation: A Guide to Clinical Decision Making

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  • Edition: 2nd
  • Format: Paperback
  • Copyright: 2009-12-18
  • Publisher: W B Saunders Co
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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 Activities
Documenting Impairments in Body Structure and Function
Documenting the Assessment: Summary and Diagnosis
Documenting Goals
Documenting the Plan of Care
Daily Notes and Progress Notes using a Modified SOAP Format
Additional Documentation Forms
Specialized Documentation
Documentation in Pediatrics - New
Payment Policy and Coding - New
Computerized Documentation - New
Guidelines for Physical Therapy Documentation
Rehabilitation Abbreviations
Answers to Exercises
Sample Evaluation Forms
Table of Contents provided by Publisher. All Rights Reserved.

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