Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy

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Lori Quinn (Associate Professor of Movement Science and Kinesiology Director, Neurorehabilitation Research Lab Teachers College, Columbia University) James Gordon, EdD, PT, FAPTA (Professor and Associate Dean Division of Biokinesiology and Physical Therapy at the Herman Ostrow School of Dentistry University of Southern California)

Documentation for Rehabilitation

A Guide to Clinical Decision Making in Physical Therapy

Lori Quinn (Associate Professor of Movement Science and Kinesiology Director, Neurorehabilitation Research Lab Teachers College, Columbia University), James Gordon, EdD, PT, FAPTA (Professor and Associate Dean Division of Biokinesiology and Physical Therapy at the Herman Ostrow School of Dentistry University of Southern California)

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English

Elsevier - Health Sciences Division
30 August 2024

Physiotherapy

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.

By: Lori Quinn (Associate Professor of Movement Science and Kinesiology Director Neurorehabilitation Research Lab Teachers College Columbia University), James Gordon, EdD, PT, FAPTA (Professor and Associate Dean Division of Biokinesiology and Physical Therapy at the Herman Ostrow School of Dentistry University of Southern California)
Imprint: Elsevier - Health Sciences Division
Country of Publication: United States
Edition: 4th edition
Dimensions: Height: 276mm, Width: 216mm,
Weight: 500g
ISBN: 9780323694308
ISBN 10: 0323694306
Pages: 304
Publication Date: 30 August 2024
Audience: College/higher education , Primary
Format: Paperback
Publisher's Status: Forthcoming

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 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