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

by Quinn, Lori

• ISBN13: 9781416062219
• ISBN10: 1416062211
• Edition: 2nd
• Format: Paperback
• Copyright: 2009-12-18
• Publisher: W B Saunders Co

Summary

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

References

Guidelines for Physical Therapy Documentation

Rehabilitation Abbreviations

Answers to Exercises

Sample Evaluation Forms

Table of Contents provided by Publisher. All Rights Reserved.