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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.
In this textbook, Quinn and Gordon provide a general approach to documentation that can be adapted to different settings, for physical therapy students and professionals. They emphasize the concept that clinical reasoning is reflected in documentation (and vice versa) and that documentation is a framework for clinical decision making. They cover each documentation component, and examples and exercises that relate to areas such as rehabilitation, women's health, health and wellness, orthopedics, and acute care. This edition has been revised and expanded and includes new chapters on payment policy and coding, legal aspects, pediatrics, and computerized documentation, and incorporates the International Classification of Functioning, Disability, and Health model.
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.
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 Instructors in educational settings can visit www.efacultylounge.com for additional materials to be used for teaching 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.
Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. The new Second Edition of Documentation Basics: A Guide for the Physical Therapist Assistant continues the path of teaching the student and clinician documentation from A to Z.
Complete & accurate documentation is one of the essential skills for a physical therapist. This book covers all the fundamentals & includes practice exercises & case studies throughout.
The most recent high-profile advocate for Americans with disabilities, actor Christopher Reeve, has highlighted for the public the economic and social costs of disability and the importance of rehabilitation. Enabling America is a major analysis of the field of rehabilitation science and engineering. The book explains how to achieve recognition for this evolving field of study, how to set priorities, and how to improve the organization and administration of the numerous federal research programs in this area. The committee introduces the "enabling-disability process" model, which enhances the concepts of disability and rehabilitation, and reviews what is known and what research priorities are emerging in the areas of: Pathology and impairment, including differences between children and adults. Functional limitationsâ€"in a person's ability to eat or walk, for example. Disability as the interaction between a person's pathologies, impairments, and functional limitations and the surrounding physical and social environments. This landmark volume will be of special interest to anyone involved in rehabilitation science and engineering: federal policymakers, rehabilitation practitioners and administrators, researchers, and advocates for persons with disabilities.
Occupation Analysis in Practice is the essential book for all future and current occupational therapists. It offers a practical approach to the analysis of occupations in real world practice. The book frames occupation as the key component for analysis and builds upon previous work limited to analysis at the activity level. It examines the interests, goals, abilities and contexts of individuals, groups, institutions and communities, along with the demands of the occupation. It presents examples of occupation analysis in different practice context including working with children, health promotion, indigenous health, medico-legal practice; mental health and occupational rehabilitation. The book has four sections. Section 1 introduces theoretical perspectives of the concept of occupation analysis and how such analysis relates to particular models of Occupational Therapy practice and the generic World Health Organisation International Classification of Functioning, Disability and Health. Section 2 discusses analysis of particular components of occupation that support practice. These include culture, spirituality, home and community environments as well as self-care and leisure. Section 3 applies analysis of occupations to particular specialties encountered in practice. Section 4 considers the application of Occupation Analysis within professional reasoning and goal setting. FEATURES International team of contributors Examples of occupation analysis proforma Application to a wide range of practice areas. Glossary of key terms Incudes the International Classification of Functioning, Disability and Health.