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Documentation for Rehabilitation

A Guide to Clinical Decision Making in Physical Therapy

Specificaties
Paperback, blz. | Engels
Elsevier Health Sciences | 2024
ISBN13: 9780323694308
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Elsevier Health Sciences e druk, 2024 9780323694308
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Samenvatting

Better patient management starts with better documentation! Documentation for Rehabilitation, 4th Edition demonstrates how to accurately document treatment progress and patient outcomes using a framework for clinical reasoning based on the International Classification for Functioning, Disability, and Health (ICF) model adopted by the American Physical Therapy Association (APTA). The documentation guidelines in this practical resource are easily adaptable to different practice settings and patient populations in physical therapy and physical therapy assisting. Realistic examples and practice exercises reinforce the understanding and application of concepts, improving skills in both documentation and clinical reasoning.Workbook/textbook format with examples and exercises in each chapter helps reinforce understanding of conceptsCoverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, nursing homes, pediatrics, school, and community settingsCase examples for a multitude of documentation types include initial evaluations, progress notes, daily notes, letters to insurance companies, Medicare documentation, and documentation in specialized settings NEW! Movement Analysis – Linking Activities and Impairments content addresses issues related to diagnosis. NEW! An eBook version, included with print purchase, provides access to all the text, figures and references, with the ability to search, customize content, make notes and highlights, and have content read aloud. Updated case examples provide clinical context for patient documentation. Revised content, including updated terminology from the latest updates to the Guide to Physical Therapist Practice, provides the most current information needed to be an effective practitioner. Updated references ensure content is current and applicable for today’s practice.

Specificaties

ISBN13:9780323694308
Taal:Engels
Bindwijze:Paperback

Inhoudsopgave

SECTION I Key Aspects of Clinical Documentation<br>1. Disablement Models and the ICF Framework<br>2. Essentials of Documentation<br>3. Legal Aspects of Documentation<br>4. Standardized Outcome Measures<br>5. Payment Policy and Coding<br>6. Electronic Medical Records<br><br>SECTION II Documenting the Initial Evaluation and Beyond: A Case-Based Guide<br>7. Clinical Decision-Making and the Initial Evaluation Format<br>8. Documenting Reason for Referral: Health Condition and Participation<br>9. Documenting Activities<br>10. Documenting Impairments in Body Structure and Function<br>11. Documenting the Assessment: Summary and Diagnosis<br>12. Developing and Documenting Effective Goals<br>13. Documenting the Plan of Care<br>14. Session Notes and Progress Notes Using a Modified SOAP Format<br>15. Special Formats: Screening Evaluations, Discharge Summaries, Letters, and Patient Education Materials<br>16. Documentation in Pediatrics
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        Documentation for Rehabilitation