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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. |
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SECTION I Key Aspects of Clinical Documentation
1 Disablement Models and the ICF Framework
2 Essentials of Documentation
3 Legal Aspects of Documentation
4 Standardized Outcome Measures
5 Payment Policy and Coding
6 Electronic Medical Records
SECTION II Documenting the Initial Evaluation and Beyond: A Case-Based Guide
7 Clinical Decision-Making and the Initial Evaluation Format
8 Documenting Reason for Referral: Health Condition and Participation
9 Documenting Activities
10 Documenting Impairments in Body Structure and Function
11 Documenting the Assessment: Summary and Diagnosis
12 Developing and Documenting Effective Goals
13 Documenting the Plan of Care
14 Session Notes and Progress Notes Using a Modified SOAP Format
15 Special Formats: Screening Evaluations, Discharge Summaries, Letters, and Patient Education Materials
16 Documentation in Pediatrics
References
Appendix A: American Physical Therapy Association Position on Documentation
Appendix B: Rehabilitation Abbreviations
Appendix C: Answers to Exercises
Appendix D: Documentation Review Sample Checklist
Appendix E: Sample Range of Motion and Strength Assessment Form
Index
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