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Better patient management starts with better documentation! Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy, 3rd Edition shows how to accurately document treatment progress and patient outcomes. Designed for use by rehabilitation professionals, documentation guidelines are easily adaptable to different practice settings and patient populations. Realistic examples and practice exercises reinforce concepts and encourage you to apply what you&aposve learned. Written by expert physical therapy educators Lori Quinn and James Gordon, this book will improve your skills in both documentation and clinical reasoning.
Author | Quinn,Gordon |
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Table Of Content | I: THEORETICAL FOUNDATIONS 1. Disablement Models, ICF Framework and Clinical Decision Making 2. Essentials of Documentation 3. Legal Aspects of Documentation 4. Standardized Outcome MeasuresNEW! 5. Payment Policy and Coding 6 Electronic Medical Records II: COMPONENTS OF PHYSICAL THERAPY DOCUMENTATION 7. Clinical Decision Making and the Initial Evaluation Format 8. Documenting Reason for Referral: Health Condition and Participation 9. Documenting Activities 10. Documenting Impairments 11. Document the Assessment: Summary and Diagnosis 12. Developing and Documenting Effective Goals 13. Documenting the Plan of Care 14. Documenting Session Notes and Progress Notes Using a Modified SOAP Note Format 15. Special Formats: Documenting Screenings, Discharge Summaries, Letters and Patient Education Materials 16. Documentation in Pediatrics References Appendix A: Guidelines: Physical Therapy Documentation of Patient/Client Management Appendix B: Rehabilitation Abbreviations Appendix C: Answers to Exercises Appendix D: Documentation Review Sample Checklist Appendix E: Strength and Range of Motion Forms |
Format | 276 x 216 (8 1/2 x 10 7/8) |
Page Count | 276 |
Publish Date | 11 Dec 2015 |