Efnisyfirlit

• Cover image
• Title page
• Table of Contents
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• Copyright
• Contributors
• Foreword
• Preface
• Acknowledgments
• Section I: Key Aspects of Clinical Documentation
  • 1. Disablement Models and the ICF Framework
    • THE CONCEPT OF 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
  • 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
    • References
  • 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
  • 4. Standardized Outcome Measures
    • LEVELS OF MEASUREMENT
    • PSYCHOMETRIC PROPERTIES
    • INSTRUMENT SELECTION: CHOOSING APPROPRIATE OUTCOME MEASURES
    • SUMMARY
    • RECOMMENDED RESOURCES
  • 5. Payment Policy and Coding
    • THE BIG PICTURE OF HEALTH CARE REFORM AND PHYSICAL THERAPY
    • THIRD-PARTY PAYERS
    • PROSPECTIVE PAYMENT, BILLING, AND CODING
    • CMS QUALITY PAYMENT PROGRAM
    • SUMMARY
    • RECOMMENDED RESOURCES
  • 6. Electronic Medical Records
    • DEVELOPING AND PRODUCING A PT EMR
    • HOW ELECTRONIC DOCUMENTATION IMPROVES PRACTICE
    • POTENTIAL PITFALLS WHEN USING ELECTRONIC DOCUMENTATION
    • WHAT PAYERS AND OTHER STAKEHOLDERS WANT FROM THE MEDICAL RECORD
    • SUMMARY
• Section II: Documenting the Initial Evaluation and Beyond: A Case-Based Guide
  • 7. Clinical Decision-Making and the Initial Evaluation Format
    • THE INITIAL EVALUATION FORMAT AND THE PHYSICAL THERAPIST MANAGEMENT PROCESS
    • DESCRIPTION OF COMPONENTS OF THE INITIAL EVALUATION
    • CASE EXAMPLES
    • CONCLUSION
    • SUMMARY
    • EXERCISE 7.1
  • 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
  • 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
  • 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
  • 11. Documenting the Assessment: Summary and Diagnosis
    • DIAGNOSIS BY PHYSICAL THERAPISTS
    • ASSESSMENT SECTION
    • COMMON PITFALLS IN ASSESSMENT DOCUMENTATION
    • SUMMARY
    • EXERCISE 11.1
    • CASE 1: OUTPATIENT
    • CASE 2: OUTPATIENT
    • CASE 3: INPATIENT
    • CASE 4: OUTPATIENT
    • CASE 5: INPATIENT REHABILITATION—BURN CENTER
  • 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 - ABCDE
    • 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
  • 13. Documenting the Plan of Care
    • DOCUMENTING THE PLAN OF CARE
    • DOCUMENTING SKILLED INTERVENTION
    • DOCUMENTING INFORMED CONSENT
    • SUMMARY
    • EXERCISE 13.1
  • 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
  • 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
  • 16. Documentation in Pediatrics
    • OVERVIEW
    • EARLY INTERVENTION
    • School-Based Intervention
    • IDEA TO GOALS FRAMEWORK
    • SUMMARY
    • EXERCISE 16.1
    • EXERCISE 16.2
    • Recommended Resources
• References
• Appendix A. American Physical Therapy Association Position on Documentation
  • PREAMBLE
  • APTA POSITION ON DOCUMENTATION
  • OPERATIONAL DEFINITIONS
  • GENERAL GUIDELINES
  • INITIAL EXAMINATION/EVALUATION
  • VISIT/ENCOUNTER
  • REEXAMINATION
  • DISCHARGE/DISCONTINUATION SUMMARY
  • 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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