Writing Patient/Client Notes: Ensuring Accuracy in Documentation

by Kettenbach, Ginge

• ISBN13: 9780803618787
• ISBN10: 0803618786
• Edition: 4th
• Format: Paperback
• Copyright: 2009-02-01
• Publisher: DAVIS F A COMPANY

Summary

A practical workbook-style text that teaches physical therapy students to take clear, concise charting notes. Includes coverage of computerized documentation, and perforated worksheets for additional practice.

Table of Contents

How to Use This Book I. Background Information 1. Introduction to Note Writing 2. Writing in a Medical Record 3. Medical Terminology/Worksheets 4. Using Abbreviations/Worksheets II. Documenting the Examination 5. The Patient/Client Management Format: Writing History/Worksheets 6. The Patient/Client Management Format: Writing Systems Review/Worksheets 7. The Patient/Client Management Format: Documenting Tests and Measures/Worksheets Review Worksheet: Writing the History, Systems Review, and Tests and Measures 8. The SOAP Note: Stating the Problem 9. The SOAP Note: Writing Subjective (S)/Worksheets 10. The SOAP Note: Writing Objective (O)/Worksheets Review Worksheet: Stating the Problem, S & O III. Documenting the Evaluation (A) 11. Writing Evaluation 12. Writing the Diagnosis 13. Writing the Prognosis/Worksheets Review Worksheet: History, Systems Review, Tests & Measures, Evaluation, Diagnosis, Prognosis Review Worksheet: Problem, S, O, A VI. Documenting the Plan of Care (P) 14. Writing Expected Outcomes (Long Term Goals)/Worksheets 15. Writing Anticipated Goals (Short Term Goals)/Worksheets 16. Documenting Planned Interventions/Worksheets Final Review Worksheet: Patient/Client Management Note: History, Systems Review, Tests & Measures, Evaluation, Diagnosis, Prognosis, Plan of Care Final Review Worksheet: Problem, S, O, A, P V. The Medical Record 17. Overview of the Medical Record 18. Legal Issues 19. Reimbursement VI. Applications of Documentation Skills 20. Applications and Variations in Note Writing 21. Alternatives: Documentation Forms and Computerized Documentation 22. The Future: Documentation Using the ICF System Appendix A: Answers to Worksheets Appendix B: Summary of the Patient/Client Management Note Contents Appendix C: Summary of the SOAP Note Contents Appendix D: Tips for Note Writing for Third Party Payers