Documentation for Rehabilitation - E-Book

Gordon James, Lori Quinn

Description

• NEW Standardized Outcome Measures chapter leads to better care and patient management by helping you select the right outcome measures for use in evaluations, re-evaluations, and discharge summaries.
• UPDATED content is based on data from current research, federal policies and APTA guidelines, including incorporation of new terminology from the Guide to Physical Therapist 3.0 and ICD-10 coding.
• EXPANDED number of case examples covers an even broader range of clinical practice areas.

Sujets

• Physical Therapy
• Allied Health Services
• Medical
• Médecine

Informations

• Publié par: Saunders
• Date de parution: 18 novembre 2015
• Nombre de lectures: 0
• EAN13: 9780323312349
• Langue: English
• Poids de l'ouvrage: 3 Mo

Extrait

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

THIRD EDITION
Lori Quinn, EdD, PT
Associate Professor
Department of Biobehavioral Sciences
Teachers College, Columbia University
New York, New York
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
Los Angeles, California
Table of Contents
Cover image
Title page
Copyright
Dedication
Contributors
Foreword
Preface
Acknowledgments
Section I Key Aspects of Clinical Documentation
Chapter 1 Disablement Models and the ICF Framework
The Concept of the Disablement and the ICF Model
Rehabilitation Is Enablement: The Reverse of Disablement
Functional Outcomes: More Than Simply a Documentation Strategy
Classification According to the ICF Framework
Summary
Exercise 1-1
Chapter 2 Essentials of Documentation
Documentation: An Overview
Types of Notes
Purposes of Note Writing
Documentation Formats
What Constitutes Documentation ?
Evidence-Based Practice
Strategies for Conciseness in Documentation
Person-First Language
Summary
Exercise 2-1 Interpreting Abbreviations
Exercise 2-2 Concise Documentation and Use of Abbreviations
Exercise 2-3 People-First Language
Chapter 3 Legal Aspects of Documentation
Documentation as a Legal Record
Privacy of the Medical Record: HIPAA and the Privacy Rule
Documentation of Informed Consent
Potential Legal Issues
Summary
Recommended Resources
Chapter 4 Standardized Outcome Measures
Levels of Measurement
Psychometric Properties
Instrument Selection: Choosing Appropriate Outcome Measures
Summary
Resources
Chapter 5 Payment Policy and Coding
The Big Picture of Health Care Reform and Physical Therapy
Third-Party Payers
Prospective Payment, Billing, and Coding
Physician Quality Reporting System
Summary
Recommended Resources
Chapter 6 Electronic Medical Record
Evidence for Electronic Medical Records
Electronic Records in Physical Therapy Practice
Drawbacks to Pen and Paper Documentation
Benefits of Electronic Medical Record
Drawbacks of Electronic Documentation
Uses of Patient Data from Electronic Medical Records
Design and Implementation of a New Computerized System
Summary
Section II Documenting the Initial Evaluation and Beyond: A Case‐Based Guide
Chapter 7 Clinical Decision Making and the Initial Evaluation Format
The Initial Evaluation Format and the Patient/Client Management Model
Description of Components of the Initial Evaluation
Case Examples
Conclusion
Summary
Exercise 7-1
Chapter 8 Documenting Reason for Referral: Health Condition and Participation
History-Taking for Health Conditions and Participation-Based Information: The First Step in Physical Therapy Diagnosis
Documenting Reason for Referral
Specificity of Documentation
Outcome Measures
Preventing Participation Restrictions
Summary
Exercise 8-1
Exercise 8-2
Exercise 8-3
Exercise 8-4
Exercise 8-5
Chapter 9 Documenting Activities
Defining and Categorizing Activities
Documenting Task Performance
Documenting Functional Activities
Measurement of Activities
Standardized Tests and Measures
Summary
Exercise 9-1
Exercise 9-2
Exercise 9-3
Chapter 10 Documenting Impairments in Body Structure and Function
Defining and Categorizing Impairments
Systems Review
Strategies for Documenting Impairments
Standardized Tests and Measures
Documenting Strength and Range of Motion
Documenting Pain
Summary
Exercise 10-1
Exercise 10-2
Chapter 11 Documenting the Assessment: Summary and Diagnosis
Diagnosis by Physical Therapists
Additional Elements of the Diagnostic Process
Assessment Section
Common Pitfalls in Assessment Documentation
Summary
Exercise 11-1
Chapter 12 Developing and Documenting Effective Goals
The Goal-Setting Process
A Traditional Approach: Short-Term and Long-Term Goals
Writing Goals at Three Different Levels
Fundamentals of Well-Written Goals
A Formula for Writing Goals
The Art of Writing Patient-Centered Goals: Going Beyond the Formula
Determining Expected Time Frames for Goals
Choosing Which Goals to Measure: Prioritizing and Benchmarking
Goal Attainment Scaling
Writing Participation and Impairment Goals
Summary
Exercise 12-1
Exercise 12-2
Chapter 13 Documenting the Plan of Care
Components of the Plan of Care
Documenting Skilled Intervention
Documenting Informed Consent
Summary
Exercise 13-1
Exercise 13-2
Chapter 14 Session Notes and Progress Notes Using a Modified SOAP Format
Modified SOAP Format
Session Notes
Summary
Exercise 14-1
Exercise 14-2
Exercise 14-3*
Exercise 14-4*
Chapter 15 Special Formats: Screening Evaluations, Discharge Summaries, Letters, and Patient Education Materials
Screening Evaluations
Discharge Summaries
Letters to Third-Party Payers to Justify Equipment or Services
Patient Education Materials
Summary
Chapter 16 Documentation in Pediatrics
Overview of Pediatric Documentation
Early Intervention
School-Based Intervention
Goal Writing in the School Setting
IDEA to GOALS
Summary
Exercise 16-1
Exercise 16-2
Resources
References
Appendix A Guidelines for Physical Therapy Documentation
Preamble
APTA Position on Documentation
Operational Definitions
General Guidelines
Initial Examination/Evaluation
Visit/Encounter
Reexamination
Discharge/Discontinuation Summary
Relationship to Vision 2020: Professionalism
Explanation of Reference Numbers
Appendix B Rehabilitation Abbreviations
General
Professional
Medical Diagnosis
Symbols
Abbreviations by Word
Appendix C Answers to Exercises
Chapter 1
Chapter 2
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Chapter 16
Appendix D Documentation Review Sample Checklist
Appendix E Sample Range of Motion and Strength Assessment Form
Index
Copyright

251 Riverport Lane
Maryland Heights, Missouri 63043
DOCUMENTATION FOR REHABILITATION: A GUIDE TO CLINICAL DECISION MAKING IN PHYSICAL THERAPY
Copyright 2016, Elsevier Inc. All Rights Reserved.
Previous editions copyrighted 2010, 2003.
ISBN: 978-0-3233-1233-2
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier's Rights Department: phone: [phone] (US) or ([phone] (UK); fax: [phone]; e-mail: [e-mail]. You may also complete your request on-line via the Elsevier website at http://www.elsevier.com/permissions .

Notice
Neither the Publisher nor the Authors assume any responsibility for any loss or injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. It is the responsibility of the treating practitioner, relying on independent expertise and knowledge of the patient, to determine the best treatment and method of application for the patient.
The Publisher
Library of Congress Cataloging-in-Publication Data
Quinn, Lori.
Documentation for rehabilitation : A guide to clinical decision making in physical therapy / Lori Quinn, James Gordon. - 2nd ed.
p. ; cm.
Rev. ed. of: Functional outcomes documentation for rehabilitation. c2003.
Includes bibliographical references and index.
ISBN 978-1-4160-6221-9 (pbk. : alk. paper)
1. Physical therapy. 2. Physical therapy assistants. 3. Medical protocols. 4. Communication in medicine. I. Gordon, James, Ed.D. II. Quinn, Lori. Functional outcomes documentation for rehabilitation. III. Title.
[DNLM: 1. Medical Records. 2. Physical Therapy Modalities. 3. Disability Evaluation. 4. Documentation. 5. Patient Care Planning. WB 460 Q74d 2010]
RM700.Q85 2010
615.8'2-dc22
2009041665
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Printed in United States of America.
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Dedication


This book is dedicated to Stephen M. Levine, PT, DPT, MSHA, FAPTA, 3/5/1962-3/3/2015
Steve's commitment to sharing his knowledge and expertise in the areas of payment, policy, and compliance reflects