Documentation for Rehabilitation
Námskeið
- SJÚ505G Skráning í sjúkraþjálfun.
Ensk lýsing:
Ensure confident clinical decisions and maximum reimbursement in a variety of practice settings such as acute care, outpatient, home care, and nursing homes with the only systematic approach to documentation for rehabilitation professionals! Revised and expanded, this hands-on textbook/workbook provides a unique framework for maintaining evidence of treatment progress and patient outcomes with a clear, logical progression.
Lýsing:
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.
Annað
- Höfundar: Lori Quinn, James Gordon
- Útgáfa:3
- Útgáfudagur: 2015-11-18
- Engar takmarkanir á útprentun
- Engar takmarkanir afritun
- Format:ePub
- ISBN 13: 9780323312349
- Print ISBN: 9780323312332
- ISBN 10: 0323312349
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
- Chapter 1 Disablement Models and the ICF Framework
- 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
- 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
- General
- Professional
- Medical Diagnosis
- Symbols
- Abbreviations by Word
- Chapter 1
- Chapter 2
- Chapter 7
- Chapter 8
- Chapter 9
- Chapter 10
- Chapter 11
- Chapter 12
- Chapter 13
- Chapter 14
- Chapter 16
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- Gerð : 208
- Höfundur : 5989
- Útgáfuár : 2015