Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy

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. INDICE: Section 1: Key Aspects of Clinical Documentation1. Disablement Models and the ICF Framework2. Essentials of Documentation3. Legal Aspects of Documentation4. Standardized Outcome Measures5. Payment Policy and Coding6. Electronic Medical RecordSection 2: Documenting the Initial Evaluation and Beyond: A Case-Based Guide7. Clinical Decision Making and the Initial Evaluation Format8. Documenting Reason for Referral: Health Condition and Participation9. Documenting Activities10. NEW! Movement Analysis - Linking Activities and Impairments11. Documenting Impairments in Body Structure and Function12. Documenting the Assessment: Summary and Diagnosis13. Developing and Documenting Effective Goals14. Documenting the Plan of Care15. Session Notes and Progress Notes Using a Modified SOAP Format16. Special Formats: Screening Evaluations, Discharge Summaries, Letters, and Patient Education Materials17. Documentation in PediatricsReferencesAppendix A: Guidelines for Physical Therapy DocumentationAppendix B: Rehabilitation AbbreviationsAppendix C: Answers to ExercisesAppendix D: Documentation Review Sample ChecklistAppendix E: Sample Range of Motion and Strength Assessment Form

• ISBN: 978-0-323-69430-8
• Editorial: Elsevier
• Encuadernacion: Rústica
• Páginas: 304
• Fecha Publicación: 26/07/2024
• Nº Volúmenes: 1
• Idioma: Inglés