Description

Book Synopsis
The ideal resource for any health care professional needing to learn or improve their skills - with simple, straight forward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management and WHO's ICF model.

Table of Contents
  • 1. Introduction to Documentation
  • I. The Health Record
  • 2. Overview of the Health Record
  • 3. Legal Aspects of the Health Record
  • 4. Reimbursement
  • 5. Reviewing the Health Record as a Physical Therapist
  • II. Documentation Basics
  • 6. Writing in a Health Record
  • 7. Introduction to Note Writing
  • 8. Medical Terminology
  • 9. Using Abbreviations
  • 10. Introduction to Documentation Using the International Classification of Functioning, Disability, and Health (ICF) System
  • III. Documenting the Examination
  • 11. The Patient/Client Management Format: Writing History, Including the Review of Systems
  • 12. The Patient/Client Management Format: Writing Systems Review and Tests and Measures
  • 13. The SOAP Note: Stating the Problem
  • 14. The SOAP Note: Writing Subjective (S), Including the Review of Systems
  • 15. The SOAP Note: Writing Objective (O)
  • IV. Documenting the Evaluation/Assessment (A)
  • 16. Writing the Evaluation / Assessment (A)
  • 17. Writing the Diagnosis (A: DIAGNOSIS)
  • 18. Writing the Prognosis (A: PROGNOSIS)
  • V. Documenting the Plan of Care (P)
  • 19. Writing Expected Outcomes and Anticipated Goals
  • 20. Documenting the Intervention Plan
  • VI. Applications of Documentation Skills
  • 21. Writing the Daily Visit Notes
  • 22. The Medicare Therapy Cap, KX Modifiers, and Functional Limitations Reporting (G Codes)
  • 23. Applications and Variations in Note Writing
  • Appendices
  • A. Summary of the Patient/Client Management Note Contents
  • B. Summary of the SOAP Note Contents
  • C. Summary of Contents of the Four Types of Notes
  • D. Tips for Note Writing for Third Party Payers
  • E. Review of Systems and Systems Review Forms

    Managing PatientClient Notes 5e

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      A Paperback / softback by Ginge Kettenbach, Sara Lynn Schlomer

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        Publisher: F.A. Davis Company
        Publication Date: 30/05/2016
        ISBN13: 9780803638204, 978-0803638204
        ISBN10: 0803638205
        Also in:
        Education Physiotherapy Rehabilitation Not Just Books Stationery

        Description

        Book Synopsis
        The ideal resource for any health care professional needing to learn or improve their skills - with simple, straight forward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management and WHO's ICF model.

        Table of Contents
        • 1. Introduction to Documentation
        • I. The Health Record
        • 2. Overview of the Health Record
        • 3. Legal Aspects of the Health Record
        • 4. Reimbursement
        • 5. Reviewing the Health Record as a Physical Therapist
        • II. Documentation Basics
        • 6. Writing in a Health Record
        • 7. Introduction to Note Writing
        • 8. Medical Terminology
        • 9. Using Abbreviations
        • 10. Introduction to Documentation Using the International Classification of Functioning, Disability, and Health (ICF) System
        • III. Documenting the Examination
        • 11. The Patient/Client Management Format: Writing History, Including the Review of Systems
        • 12. The Patient/Client Management Format: Writing Systems Review and Tests and Measures
        • 13. The SOAP Note: Stating the Problem
        • 14. The SOAP Note: Writing Subjective (S), Including the Review of Systems
        • 15. The SOAP Note: Writing Objective (O)
        • IV. Documenting the Evaluation/Assessment (A)
        • 16. Writing the Evaluation / Assessment (A)
        • 17. Writing the Diagnosis (A: DIAGNOSIS)
        • 18. Writing the Prognosis (A: PROGNOSIS)
        • V. Documenting the Plan of Care (P)
        • 19. Writing Expected Outcomes and Anticipated Goals
        • 20. Documenting the Intervention Plan
        • VI. Applications of Documentation Skills
        • 21. Writing the Daily Visit Notes
        • 22. The Medicare Therapy Cap, KX Modifiers, and Functional Limitations Reporting (G Codes)
        • 23. Applications and Variations in Note Writing
        • Appendices
        • A. Summary of the Patient/Client Management Note Contents
        • B. Summary of the SOAP Note Contents
        • C. Summary of Contents of the Four Types of Notes
        • D. Tips for Note Writing for Third Party Payers
        • E. Review of Systems and Systems Review Forms

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