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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.
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.
This is a comprehensive textbook for the documentation course required in all Physical Therapy programs. The textbook incorporates current APTA terminology and covers every aspect of documentation including reimbursement and billing, coding, legal issues, PT and PTA communication, as well as utilization review and quality assurance. (Midwest).
Because communication among health care professionals can mean the difference between patient life and death, clear and effective patient care documentation is as important as the delivery of care itself. The rehabilitation professional faces formidable documentation responsibilities. Patient care documentation created by the rehabilitation professional must be accurate, comprehensive, concise, objective, and timely. In an interdisciplinary health care environment, documentation must also be expeditiously communicated to other professionals on the health care team.
- NEW! The Skin and Wound Healing chapter looks at the numerous tools available to assist in objectively monitoring and treating a patient with an acute or chronic wound. - NEW! Rotator Cuff Pathology chapter highlights the anatomy, function, and etiology of the rotary cuff, and addresses rotary cuff injuries, physical examination, and non-operative and operative treatment. - UPDATED! Substantially revised chapter on the Thoracic Ring ApproachTM facilitates clinical reasoning for the treatment of the thoracic spine and ribs through the assessment and treatment of thoracic spine disorders and how they relate to the whole kinetic chain. - UPDATED! Revised Lumbar Spine – Treatment of Motor Control Disorders chapter explores some of the research evidence and clinical reasoning pertaining to instability of the lumbar spine so you can better organize your knowledge for immediate use in the clinical setting. - UPDATED! Significantly revised chapter on the treatment of pelvic pain and dysfunction presents an overview of specific pathologies pertaining to the various systems of the pelvis — and highlights how "The Integrated Systems Model for Disability and Pain" facilitates evidence-based management of the often complex patient with pelvic pain and dysfunction. - NEW! Musculoskeletal Bone and Soft Tissue Tumors chapter covers common bones tumors, anatomic considerations and rehabilitation, pediatric patients, and amputation related to cancer. - UPDATED! Thoroughly revised chapters with additional references ensure you get the most recent evidence and information available. - NEW! Full color design and illustration program reflects what you see in the physical world to help you recognize and understand concepts more quickly.
- NEW! Updated content throughout the text reflects the current state of primary care and physical therapy practice. - NEW! New chapter on electrodiagnostic testing helps familiarize physical therapists with indications for electrodiagnostic testing and implications of test results to their clinical decision-making. - NEW! New chapter on patients with a history of trauma emphasizes the red flags that physical therapists need to recognize for timely patient referral for appropriate tests. - NEW! Updated information on how to screen and examine the healthy population enhances understanding of the foundations of practice and the role that physical therapists can fill in primary care models.
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.
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.
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.