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
• 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
  • Abbreviations by Word
• Appendix C Answers to Exercises
  • Chapter 1
  • Chapter 2
  • Chapter 7
  • Chapter 8
  • Chapter 9
  • Chapter 10
  • Chapter 11
  • Chapter 12
  • Chapter 13
  • Chapter 14
  • Chapter 16
• Appendix D Documentation Review Sample Checklist
• Appendix E Sample Range of Motion and Strength Assessment Form
• Index

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