Writing Patient/Client Notes

Ensuring Accuracy in Documentation

Häftad, Engelska, 2016

Av Ginge Kettenbach, Sarah Lynn Schlomer, Jill Fitzgerald

809 kr

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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.

Produktinformation

Utgivningsdatum2016-05-30
Mått216 x 279 x 19 mm
Vikt706 g
FormatHäftad
SpråkEngelska
Antal sidor304
Upplaga5
FörlagF.A. Davis Company
ISBN9780803638204

Tillhör följande kategorier

Rehabilitering inom Medicin
Fysioterapi inom Medicin

1. Introduction to DocumentationI. The Health Record2. Overview of the Health Record3. Legal Aspects of the Health Record4. Reimbursement5. Reviewing the Health Record as a Physical TherapistII. Documentation Basics6. Writing in a Health Record7. Introduction to Note Writing8. Medical Terminology9. Using Abbreviations10. Introduction to Documentation Using the International Classification of Functioning, Disability, and Health (ICF) SystemIII. Documenting the Examination11. The Patient/Client Management Format: Writing History, Including the Review of Systems12. The Patient/Client Management Format: Writing Systems Review and Tests and Measures13. The SOAP Note: Stating the Problem 14. The SOAP Note: Writing Subjective (S), Including the Review of Systems15. 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 Goals20. Documenting the Intervention PlanVI. Applications of Documentation Skills21. Writing the Daily Visit Notes22. The Medicare Therapy Cap, KX Modifiers, and Functional Limitations Reporting (G Codes)23. Applications and Variations in Note WritingAppendicesA. Summary of the Patient/Client Management Note ContentsB. Summary of the SOAP Note ContentsC. Summary of Contents of the Four Types of NotesD. Tips for Note Writing for Third Party PayersE. Review of Systems and Systems Review Forms