Efnisyfirlit

• Cover image
• Title page
• Table of Contents
• Copyright
• Dedication
• Contributors
• Foreword
• Preface
• Acknowledgments
• Section I Key Aspects of Clinical Documentation
• Chapter 1 Disablement Models and the ICF Framework
• The Concept of the Disablement and the ICF Model
• Rehabilitation Is Enablement: The Reverse of Disablement
• Functional Outcomes: More Than Simply a Documentation Strategy
• Classification According to the ICF Framework
• Summary
• Exercise 1-1
• Chapter 2 Essentials of Documentation
• Documentation: An Overview
• Types of Notes
• Purposes of Note Writing
• Documentation Formats
• What Constitutes “Documentation”?
• Evidence-Based Practice
• Strategies for Conciseness in Documentation
• Person-First Language
• Summary
• Exercise 2-1 Interpreting Abbreviations
• Exercise 2-2 Concise Documentation and Use of Abbreviations
• Exercise 2-3 People-First Language
• Chapter 3 Legal Aspects of Documentation
• Documentation as a Legal Record
• Privacy of the Medical Record: HIPAA and the Privacy Rule
• Documentation of Informed Consent
• Potential Legal Issues
• Summary
• Recommended Resources
• Chapter 4 Standardized Outcome Measures
• Levels of Measurement
• Psychometric Properties
• Instrument Selection: Choosing Appropriate Outcome Measures
• Summary
• Resources
• Chapter 5 Payment Policy and Coding
• The Big Picture of Health Care Reform and Physical Therapy
• Third-Party Payers
• Prospective Payment, Billing, and Coding
• Physician Quality Reporting System
• Summary
• Recommended Resources
• Chapter 6 Electronic Medical Record
• Evidence for Electronic Medical Records
• Electronic Records in Physical Therapy Practice
• Drawbacks to Pen and Paper Documentation
• Benefits of Electronic Medical Record
• Drawbacks of Electronic Documentation
• Uses of Patient Data from Electronic Medical Records
• Design and Implementation of a New Computerized System
• Summary
• Section II Documenting the Initial Evaluation and Beyond: A Case‐Based Guide
• Chapter 7 Clinical Decision Making and the Initial Evaluation Format
• The Initial Evaluation Format and the Patient/Client Management Model
• Description of Components of the Initial Evaluation
• Case Examples
• Conclusion
• Summary
• Exercise 7-1
• Chapter 8 Documenting Reason for Referral: Health Condition and Participation
• History-Taking for Health Conditions and Participation-Based Information: The First Step in Physical Therapy Diagnosis
• Documenting Reason for Referral
• Specificity of Documentation
• Outcome Measures
• Preventing Participation Restrictions
• Summary
• Exercise 8-1
• Exercise 8-2
• Exercise 8-3
• Exercise 8-4
• Exercise 8-5
• Chapter 9 Documenting Activities
• Defining and Categorizing Activities
• Documenting Task Performance
• Documenting Functional Activities
• Measurement of Activities
• Standardized Tests and Measures
• Summary
• Exercise 9-1
• Exercise 9-2
• Exercise 9-3
• Chapter 10 Documenting Impairments in Body Structure and Function
• Defining and Categorizing Impairments
• Systems Review
• Strategies for Documenting Impairments
• Standardized Tests and Measures
• Documenting Strength and Range of Motion
• Documenting Pain
• Summary
• Exercise 10-1
• Exercise 10-2
• Chapter 11 Documenting the Assessment: Summary and Diagnosis
• Diagnosis by Physical Therapists
• Additional Elements of the Diagnostic Process
• Assessment Section
• Common Pitfalls in Assessment Documentation
• Summary
• Exercise 11-1
• Chapter 12 Developing and Documenting Effective Goals
• The Goal-Setting Process
• A Traditional Approach: Short-Term and Long-Term Goals
• Writing Goals at Three Different Levels
• Fundamentals of Well-Written Goals
• A Formula for Writing Goals
• The Art of Writing Patient-Centered Goals: Going Beyond the Formula
• Determining Expected Time Frames for Goals
• Choosing Which Goals to Measure: Prioritizing and Benchmarking
• Goal Attainment Scaling
• Writing Participation and Impairment Goals
• Summary
• Exercise 12-1
• Exercise 12-2
• Chapter 13 Documenting the Plan of Care
• Components of the Plan of Care
• Documenting Skilled Intervention
• Documenting Informed Consent
• Summary
• Exercise 13-1
• Exercise 13-2
• Chapter 14 Session Notes and Progress Notes Using a Modified SOAP Format
• Modified SOAP Format
• Session Notes
• Summary
• Exercise 14-1
• Exercise 14-2
• Exercise 14-3*
• Exercise 14-4*
• Chapter 15 Special Formats: Screening Evaluations, Discharge Summaries, Letters, and Patient Education Materials
• Screening Evaluations
• Discharge Summaries
• Letters to Third-Party Payers to Justify Equipment or Services
• Patient Education Materials
• Summary
• Chapter 16 Documentation in Pediatrics
• Overview of Pediatric Documentation
• Early Intervention
• School-Based Intervention
• Goal Writing in the School Setting
• IDEA to GOALS
• Summary
• Exercise 16-1
• Exercise 16-2
• Resources
• References
• Appendix A Guidelines for Physical Therapy Documentation
• Preamble
• APTA Position on Documentation
• Operational Definitions
• General Guidelines
• Initial Examination/Evaluation
• Visit/Encounter
• Reexamination
• Discharge/Discontinuation Summary
• Relationship to Vision 2020: Professionalism
• Explanation of Reference Numbers
• Appendix B Rehabilitation Abbreviations
• General
• Professional
• Medical Diagnosis
• Symbols
• Abbreviations by Word
• Appendix C Answers to Exercises
• Chapter 1
• Chapter 2
• Chapter 7
• Chapter 8
• Chapter 9
• Chapter 10
• Chapter 11
• Chapter 12
• Chapter 13
• Chapter 14
• Chapter 16
• Appendix D Documentation Review Sample Checklist
• Appendix E Sample Range of Motion and Strength Assessment Form
• Index