Documentation for Rehabilitation A Guide to Clinical Decision Making in Physical Therapy 3rd Edition by Lori Quinn, James Gordon ISBN 0323312330 9780323312332

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Product details: 

ISBN 10: 0323312330 

ISBN 13: 9780323312332

Author: Lori Quinn, James Gordon

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’ve learned. Written by expert physical therapy educators Lori Quinn and James Gordon, this book will improve your skills in both documentation and clinical reasoning.

• A practical framework shows how to organize and structure PT records, making it easier to document functional outcomes in many practice settings, and is based on the International Classification for Functioning, Disability, and Health (ICF) model — the one adopted by the APTA.
• Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, and nursing homes, as well as a separate chapter on documentation in pediatric settings.
• Guidelines to systematic documentation describe how to identify, record, measure, and evaluate treatment and therapies — especially important when insurance companies require evidence of functional progress in order to provide reimbursement.
• Workbook/textbook format uses examples and exercises in each chapter to reinforce your understanding of concepts.

• NEW Standardized Outcome Measures chapter leads to better care and patient management by helping you select the right outcome measures for use in evaluations, re-evaluations, and discharge summaries.
• UPDATED content is based on data from current research, federal policies and APTA guidelines, including incorporation of new terminology from the Guide to Physical Therapist 3.0 and ICD-10 coding.
• EXPANDED number of case examples covers an even broader range of clinical practice areas.

Table of contents: 

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

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