Documentation for Rehabilitation: A Guide to Clinical Decision Making » (2nd Edition)

Ensure confident clinical decisions and maximum reimbursement in a variety of practice settings such as acute care, outpatient, home care, and nursing homes with the only systematic approach to documentation for rehabilitation professionals! Revised and expanded, this hands-on textbook/workbook provides a unique framework for maintaining evidence of treatment progress and patient outcomes with a clear, logical progression. Extensive examples and exercises in each chapter reinforce concepts and encourage you to apply what you’ve learned to realistic practice scenarios.

• UNIQUE! Combination textbook/workbook format reinforces your understanding and tests your ability to apply concepts through practice exercises.
• UNIQUE! Systematic approach to documenting functional outcomes provides a practical framework for success in numerous practice settings.
• Case studies show you how to format goals through realistic client examples.
• Practice exercises provide valuable experience applying concepts to common clinical problems.

• Four NEW chapters address additional aspects of documentation that rehabilitation professionals will encounter in practice:



• Legal aspects of documentation
• Documentation in pediatrics
• Payment policy and coding
• Computerized documentation

I. Theoretical Foundations & Documentation Essentials
1. Disablement models, ICF Framework, and Clinical Decision Making
2. Essentials of Documentation
3. Legal Aspects of Documentation - New
4. Clinical Decision Making and the Initial Evaluation Format

II. Components of Physical Therapy Documentation
5. Documenting History: Background Information and Health Condition
6. Documenting History: Participation and Social History
7. Documenting Activities
8. Documenting Impairments in Body Structure and Function
9. Documenting the Assessment: Summary and Diagnosis
10. Documenting Goals
11. Documenting the Plan of Care
12. Daily Notes and Progress Notes using a Modified SOAP Format

III. Additional Documentation Forms
13. Specialized Documentation
14. Documentation in Pediatrics - New
15. Payment Policy and Coding - New
16. Computerized Documentation - New

References
Appendix A. Guidelines for Physical Therapy Documentation Appendix B. Rehabilitation Abbreviations Appendix C. Answers to Exercises Appendix D. Sample Evaluation Forms