Communicating Clinical Decision-Making Through Documentation: Coding, Payment, and Patient Categorization

Häftad, Engelska, 2021

AvEric Shamus,Debra Stern,William F. McGehee

1 659 kr

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Clear, concise, and simple to follow—everything you need to master the documentation process quickly and easily

Communicating Clinical Decision Making Through Documentation is the top choice for professionals and students seeking complete coverage of the documentation process including billing and coding. It shows how to ensure every service rendered and billed is supported by showing what to document, how to do it, and why it is so important.

This text includes a refreshing student-friendly approach to the topic. You will find an abundance of cases portraying real-life case scenarios and it delivers must-know information on writing patient/client care notes, incorporating document guidelines, documenting clinical decision making (includes evidence-based practice), and performing billing and coding tasks.

With Communicating Clinical Decision Making Through Documentation, you’ll effectively maintain and organize records, record appropriate information, and receive proper payment based on the documentation content.

A to Z coverage of physical therapy documentation, including:

Documentation Standards and Guidelines
Medicare
Home Health
Electronic Medical Records (EMR)
International Classification of Functioning (ICF) Model and Application
Pediatrics
Legal Issue
Utilization Review & Management
Skilled Nursing Facilities
Sample Documentation Content
Initial Examination and Evaluation Criteria
Continuum of Care Content and Goal Writing Exercises
Documentation Aspects of Supervising PTAs
Abbreviations
Payment
ICD-10 and CPT Codes and Application
Chapter Review Questions
Content Principles

Produktinformation

Utgivningsdatum2021-03-24
Mått218 x 274 x 22 mm
Vikt1 301 g
FormatHäftad
SpråkEngelska
FörlagMcGraw-Hill Education
ISBN9781260440669

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Fysioterapi inom Medicin

Eric Shamus, DPT, PhD, CSCS has taught national and international continuing education courses on Orthopeadics, Sports Medicine, and Manual Therapy, with a focus on documentation and reimbursement. He is presently a professor at Florida Gulf Coast University and works at an outpatient orthopedic facility in Fort Lauderdale. Debra F. Stern, PT, MSM, DBA is an Associate Professor at Nova Southeastern University in Fort Lauderdale, FL. She serves as a clinical instructor with a focus on geriatrics, neuromuscular disorders, and also coordinates service learning experiences for the school's PT department. She received her BS in Physical Therapy from SUNY Buffalo, her MSM from Rollins College, and her DBAS at Nova Southeastern.

ContentsContributorsPrefaceAcknowledgementsSECTION 1 How to Write Patient Care Notes1. Introduction, Background, Purpose, and General Rules for Health Information Management2. Record Organization and General Principles3. Application of Models for Organization and Guidelines for Content4. The Electronic Medical Record5. Content Standardization and Component Requirements6. Documentation for Pediatrics7. Documentation for Home Health8. Documentation for Certified Nursing HomesSECTION 2 How to Document Clinical Decision-Making9. Evidence-Based Practice10. Clinical Decision-Making11. Legal Issues in the Medical Record12. Utilization Review and Utilization ManagementSECTION 3 Payment and Coding13. Coding14. Documentation Content Principles15. Alternative Payment ModelsSECTION 4 Steps and Framework for Coding and Documentation16. Documentation Writing Examples and WorksheetsAppendix A AbbreviationsAppendix B OASIS DAppendix C CMS Form 1500 with InstructionsAppendix D ICD-10 GuidelinesAppendix E APTA Guidelines for Physical Therapy DocumentationAppendix F APTA Documentation Review ChecklistIndex