Writing Patient/Client Notes Ensuring Accuracy in Documentation
Heftet /
2016
/ Engelsk
Produktdetaljer
ISBN
9780803638204
Publisert
2016-05-30
Utgave
5. utgave
Utgiver
Vendor
F.A. Davis Company
Vekt
706 gr
Høyde
279 mm
Bredde
216 mm
Dybde
19 mm
Aldersnivå
P, 06
Språk
Product language
Engelsk
Format
Product format
Heftet
Antall sider
304
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.
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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.
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- 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
Les mer
Produktdetaljer
ISBN
9780803638204
Publisert
2016-05-30
Utgave
5. utgave
Utgiver
Vendor
F.A. Davis Company
Vekt
706 gr
Høyde
279 mm
Bredde
216 mm
Dybde
19 mm
Aldersnivå
P, 06
Språk
Product language
Engelsk
Format
Product format
Heftet
Antall sider
304