Documentation for Rehabilitation, 4th Edition. A Guide to Clinical Decision Making in Physical Therapy

Better patient management starts with better documentation! Documentation for Rehabilitation, 4^th 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.

New to this edition

• 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.

Key Features

• Workbook/textbook format with examples and exercises in each chapter helps reinforce understanding of concepts.
• Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, nursing homes, pediatrics, school, and community settings.
• Case 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.

CONTENTS

Section 1: Key Aspects of Clinical Documentation
1. Disablement Models and the ICF Framework
2. Essentials of Documentation
3. Legal Aspects of Documentation
4. Standardized Outcome Measures
5. Payment Policy and Coding
6. Electronic Medical Record
Section 2: Documenting the Initial Evaluation and Beyond: A Case-Based Guide
7. Clinical Decision Making and the Initial Evaluation Format
8. Documenting Reason for Referral: Health Condition and Participation
9. Documenting Activities
10. NEW! Movement Analysis – Linking Activities and Impairments
11. Documenting Impairments in Body Structure and Function
12. Documenting the Assessment: Summary and Diagnosis
13. Developing and Documenting Effective Goals
14. Documenting the Plan of Care
15. Session Notes and Progress Notes Using a Modified SOAP Format
16. Special Formats: Screening Evaluations, Discharge Summaries, Letters, and Patient Education Materials
17. Documentation in Pediatrics
References
Appendix A: Guidelines for Physical Therapy Documentation
Appendix B: Rehabilitation Abbreviations
Appendix C: Answers to Exercises
Appendix D: Documentation Review Sample Checklist
Appendix E: Sample Range of Motion and Strength Assessment Form