Writing Patient/Client Notes
Ensuring Accuracy in Documentation
5th Edition
Published on 30. May 2016
Book
Paperback/Softback
304 pages
978-0-8036-3820-4 (ISBN)
Description
Master the hows and whys of documentation!
Develop all of the skills you need to write clear, concise, and defensible patient/client care notes using a variety of tools, including SOAP notes.
This is 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.
Section by section you'll learn how to document clearly and accurately, while exercise by exercise you'll practice mastering every step.
Develop all of the skills you need to write clear, concise, and defensible patient/client care notes using a variety of tools, including SOAP notes.
This is 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.
Section by section you'll learn how to document clearly and accurately, while exercise by exercise you'll practice mastering every step.
More details
Edition
Fifth Edition
Language
English
Place of publication
Pennsylvania
United States
Target group
Professional and scholarly
Edition type
New edition
Product notice
Paperback (trade)
Unsewn / adhesive bound
Illustrations
10 illustrations
Dimensions
Height: 277 mm
Width: 213 mm
Thickness: 13 mm
Weight
680 gr
ISBN-13
978-0-8036-3820-4 (9780803638204)
Copyright in bibliographic data and cover images is held by Nielsen Book Services Limited or by the publishers or by their respective licensors: all rights reserved.
Schweitzer Classification
Persons
Associate Professor, Program in Physical Therapy, Saint Louis University, St. Louis, Missouri
Content
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
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