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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'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.
This hands-on textbook/workbook teaches readers how to document functional outcomes in a clear, logical progression. Extensive examples and exercises in each chapter highlight the essential points of functional outcomes documentation, designed to help improve client function and reduce disability as well as provide evidence of functional progress for insurance payment and reimbursement.
Four NEW chapters address additional aspects of documentation that rehabilitation professionals will encounter in practice: Legal aspects of documentation Documentation in pediatrics Payment policy and coding Computerized documentation
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. Workbook/textbook format with examples and exercises in each chapter helps reinforce understanding of concepts. Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, nursing homes, pediatrics, school, and community settings. Case examples for a multitude of documentation types include initial evaluations, progress notes, daily notes, letters to insurance companies, Medicare documentation, and documentation in specialized settings. NEW! Movement Analysis – Linking Activities and Impairments content addresses issues related to diagnosis. NEW! An eBook version, included with print purchase, provides access to all the text, figures and references, with the ability to search, customize content, make notes and highlights, and have content read aloud. Updated case examples provide clinical context for patient documentation. Revised content, including updated terminology from the latest updates to the Guide to Physical Therapist Practice, provides the most current information needed to be an effective practitioner. Updated references ensure content is current and applicable for today’s practice.
Documentation for Physical Therapist Practice: A Clinical Decision Making Approach provides the framework for successful documentation. It is synchronous with Medicare standards as well as the American Physical Therapy Association's recommendations for defensible documentation. It identifies documentation basics which can be readily applied to a broad spectrum of documentation formats including paper-based and electronic systems. This key resource utilizes a practical clinical decision making approach and applies this framework to all aspects of documentation. This text emphasizes how the common and standard language of the Guide to Physical Therapist Practice and the International Classification of Functioning, Disability, and Health (ICF) model can be integrated with a physical therapist's clinical reasoning process and a physical therapist assistant's skill set to produce successful documentation. Includes content on documentation formations: Initial Evaluations, Re-examination Notes, Daily Notes, Conclusion of the Episode of Care Summaries, Home Exercise Program Reviews all the important issues related to style, types of documentation, and utilization of documentation Covers documentation relevant in different settings (inpatient, home health, skilled nursing facility, outpatient) Helps students learn how to report findings and demonstrate an appropriate interpretation of results Includes up-to-date information in line with APTA Guidelines for Defensible Documentation, World Health Organization, International Classification of Functioning Disability and Health Mode, and Medicare Reviews electronic documentation, ICD-9, ICD-10, and CPT codes Includes important chapters on Interprofessional Communication, Legal Aspects, Principles of Measurement
This is a Pageburst digital textbook; 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. Extensive examples and exercises in each chapter reinforce concepts and encourage you to apply what you've learned to realistic practice scenarios. UNIQUE! Combination textbook/workbook format reinforces your understanding and tests your ability to apply concepts through practice exercises. UNIQUE! Systematic approach to documenting functional outcomes provides a practical framework for success in numerous practice settings. Case studies show you how to format goals through realistic client examples. Practice exercises provide valuable experience applying concepts to common clinical problems. Four NEW chapters address additional aspects of documentation that rehabilitation professionals will encounter in practice: Legal aspects of documentation Documentation in pediatrics Payment policy and coding Computerized documentation
The Handbook of Psychosocial Rehabilitation is designed as a clinical handbook for practitioners in the field of mental health. It recognises the wide-ranging impact of mental illness and its ramifications on daily life. The book promotes a recovery model of psychosocial rehabilitation and aims to empower clinicians to engage their clients in tailored rehabilitation plans. The authors distil relevant evidence from the literature, but the focus is on the clinical setting. Coverage includes the service environment, assessment, maintaining recovery-focussed therapeutic relationships, the role of pharmacotherapy, intensive case management and vocational rehabilitation.
Psychosocial Rehabilitation is a comprehensive ready- reference for mental health practitioners and students, providing practical advice on the full range of interventions for psychosocial rehabilitation. It contextualises the interventions described and provides pointers to enable the reader to explore the theory and research. This manual recognises the wide-ranging impact of mental illness and its ramifications on daily life, and promotes a recovery model of psychosocial rehabilitation and aims to empower clinicians to engage their clients in tailored rehabilitation plans. The book is divided into five key sections. Section 1 looks at assessment covering tools available in the public domain, instruments, scoring systems, norms and applications for diagnosis and measurement of symptoms, cognitive functioning, impairment and recovery. Section 2 covers the full range of therapeutic interventions and offers advice on training and supervision requirements and evaluation of process, impact and outcome. Section 3 provides manuals and programs for interventions effectively provided as group activities. Section 4 explains how to design a full programme that integrates therapeutic interventions with group programmes as well as services provided by other agencies. The final section looks at peer support and self help, providing manuals and resources that support programmes and interventions not requiring professional or practitioner direction.
Newly updated and revised, Physical Therapy Documentation: From Examination to Outcome, Third Edition provides physical therapy students, educators, and clinicians with essential information on documentation for contemporary physical therapy practice. Complete and accurate documentation is one of the most essential skills for physical therapists. In this text, authors Mia L. Erickson, Rebecca McKnight, and Ralph Utzman teach the knowledge and skills necessary for correct documentation of physical therapy services, provide guidance for readers in their ethical responsibility to quality record-keeping, and deliver the mechanics of note writing in a friendly, approachable tone. Featuring the most up-to-date information on proper documentation and using the International Classification of Functioning, Disabilities, and Health (ICF) model as a foundation for terminology, the Third Edition includes expanded examples across a variety of practice settings as well as new chapters on: Health informatics Electronic medical records Rules governing paper and electronic records Billing, coding, and outcomes measures Included with the text are online supplemental materials for faculty use in the classroom. An invaluable reference in keeping with basic documentation structure, Physical Therapy Documentation: From Examination to Outcome, Third Edition is a necessity for both new and seasoned physical therapy practitioners.