About the Book
Complete and accurate documentation is one of the most essential skills for a physical therapist to develop and use effectively. Necessary for both new and experienced practitioners, the new and updated Second Edition of Physical Therapy Documentation: From Examination to Outcome will teach and explain physical therapy documentation from A to Z.
Physical Therapy Documentation, Second Edition provides individuals with the knowledge and skills for documenting physical therapy services. The text begins with several chapters of background information that give the rationale for quality documentation. Physical Therapy Documentation, Second Edition provides the physical therapist’s ethical responsibility for quality record keeping. The mechanics of note writing are delivered in a manner friendly to those who are learning the basic elements of documentation.
Mia Erickson, Ralph Utzman, and Rebecca McKnight also include chapters on professional responsibilities and reimbursement issues commonly associated with documentation that are important to physical therapists. Each chapter includes examples and opportunities for practice covering a variety of physical therapy patients and settings.
Features in the Second Edition: - Multiple sections covering electronic documentation, including the positive and negative aspects and common pitfalls.
- Use of research evidence on integrating and documenting tests and measures is provided in the mechanics of note writing.
- Multiple templates for documenting initial notes, interim notes, and discharge summaries are given but deviation from these templates, such as during use of the electronic record, are also discussed.
- Ethical and regulatory issues related to documentation of physical therapy care.
- Increased emphasis on documenting contemporary concepts such as skilled services and medical necessity.
In keeping with the familiarity of the basic SOAP structure, Physical Therapy Documentation, Second Edition breaks down the components of the A and P portions of the note; however, information is provided that allows readers to create documentation that blends these sections into a “Plan of Care.”
Physical Therapy Documentation: From Examination to Outcome, Second Edition provides physical therapy students, educators, and clinicians with a valuable reference tool for documentation within contemporary physical therapy practice.
Table of Contents:
- Acknowledgments
- About the Authors
- Preface
- Chapter 1: Overview of Disablement — Mia L. Erickson, PT, EdD, CHT, ATC
- Chapter 2: Reasons for Documenting in Physical Therapy — Mia L. Erickson, PT, EdD, CHT, ATC
- Chapter 3: Ethical and Regulatory Issues in Physical Therapy Documentation — Ralph R. Utzman, PT, MPH, PhD
- Chapter 4: Documenting Patient/Client Management: An Overview — Mia L. Erickson, PT, EdD, CHT, ATC and Rebecca McKnight, PT, MS
- Chapter 5: Documentation Formats — Mia L. Erickson, PT, EdD, CHT, ATC
- Chapter 6: Rules for Writing in Medical Records — Mia L. Erickson, PT, EdD, CHT, ATC
- Chapter 7: Documenting Patient Histories and Interviews — Ralph R. Utzman, PT, MPH, PhD
- Chapter 8: Documenting Objective Information — Ralph R. Utzman, PT, MPH, PhD and Mia L. Erickson, PT, EdD, CHT, ATC
- Chapter 9: Writing the Assessment and the Plan — Mia L. Erickson, PT, EdD, CHT, ATC and Rebecca McKnight, PT, MS
- Chapter 10: Interim Documentation — Mia L. Erickson, PT, EdD, CHT, ATC and Rebecca McKnight, PT, MS
- Chapter 11: Patient Outcomes and Discharge Summaries — Mia L. Erickson, PT, EdD, CHT, ATC
- Chapter 12: Documentation and Reimbursement — Ralph R. Utzman, PT, MPH, PhD
- Appendices
- Appendix A Guidelines: Physical Therapy Documentation of Patient/Client Management
- Appendix B Preferred Practice Patterns
- Appendix C Sample Forms
- Appendix D Abbreviations and Symbols
- Appendix E Assessing Change
- Glossary
- Financial Disclosures
- Index
