Writing patient/client notes (Record no. 30085)
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| 000 -LEADER | |
|---|---|
| fixed length control field | 03929nam a2200373 i 4500 |
| 001 - CONTROL NUMBER | |
| control field | FADAVISB0000534 |
| 006 - FIXED-LENGTH DATA ELEMENTS--ADDITIONAL MATERIAL CHARACTERISTICS | |
| fixed length control field | m eo d |
| 007 - PHYSICAL DESCRIPTION FIXED FIELD--GENERAL INFORMATION | |
| fixed length control field | cr cn |||m|||a |
| 008 - FIXED-LENGTH DATA ELEMENTS--GENERAL INFORMATION | |
| fixed length control field | 190222s2016 ob 000 0 eng d |
| 020 ## - INTERNATIONAL STANDARD BOOK NUMBER | |
| International Standard Book Number | 9780803638204 |
| 020 ## - INTERNATIONAL STANDARD BOOK NUMBER | |
| International Standard Book Number | 9780803658462 |
| 041 0# - LANGUAGE CODE | |
| Language code of text/sound track or separate title | eng |
| 050 00 - LIBRARY OF CONGRESS CALL NUMBER | |
| Classification number | RM701.6 |
| 082 00 - DEWEY DECIMAL CLASSIFICATION NUMBER | |
| Classification number | 615.8/2 |
| 100 1# - MAIN ENTRY--PERSONAL NAME | |
| Personal name | Kettenbach, Ginge. |
| 9 (RLIN) | 34354 |
| 245 10 - TITLE STATEMENT | |
| Title | Writing patient/client notes |
| Medium | [electronic resource] : |
| Remainder of title | ensuring accuracy in documentation / |
| Statement of responsibility, etc. | Ginge Kettenbach, Sara Lynn Schlomer. |
| 250 ## - EDITION STATEMENT | |
| Edition statement | 5th ed. |
| 264 #1 - PRODUCTION, PUBLICATION, DISTRIBUTION, MANUFACTURE, AND COPYRIGHT NOTICE | |
| Place of production, publication, distribution, manufacture | [Place of publication not identified] : |
| Name of producer, publisher, distributor, manufacturer | F.A. Davis Company, |
| Date of production, publication, distribution, manufacture, or copyright notice | 2016. |
| 264 #4 - PRODUCTION, PUBLICATION, DISTRIBUTION, MANUFACTURE, AND COPYRIGHT NOTICE | |
| Date of production, publication, distribution, manufacture, or copyright notice | ©2016 |
| 300 ## - PHYSICAL DESCRIPTION | |
| Extent | 1 online resource (295 pages) |
| 336 ## - CONTENT TYPE | |
| Content type term | text |
| Content type code | txt |
| Source | rdacontent |
| 337 ## - MEDIA TYPE | |
| Media type term | computer |
| Media type code | c |
| Source | rdamedia |
| 338 ## - CARRIER TYPE | |
| Carrier type term | online resource |
| Carrier type code | cr |
| Source | rdacarrier |
| 504 ## - BIBLIOGRAPHY, ETC. NOTE | |
| Bibliography, etc. note | Includes bibliographical references and index. |
| 505 0# - FORMATTED CONTENTS NOTE | |
| Formatted contents note | Writing patient/client notes : ensuring accuracy in documentation -- Preface -- Contributors -- Reviewers -- Table of Contents -- Chapter 1: Introduction to Documentation -- Part I: The Health Record; Chapter 2: Overview of the Health Record -- Chapter 3: Legal Aspects of the Health Record -- Chapter 4: Reimbursement -- Chapter 5: Reviewing the Health Record as a Physical Therapist -- Part II: Documentation Basics; Chapter 6: Writing in a Health Record -- Chapter 7: Introduction to Note Writing -- Chapter 8: Medical Terminology -- Chapter 9: Using Abbreviations -- Chapter 10: Introduction to Documentation Using the International Classification of Functioning, Disability, and Health (ICF) System -- Part III: Documenting the Examination -- Chapter 11: The Patient/Client Management Format: Writing History, Including the Review of Systems -- Chapter 12: The Patient/Client Management Format: Writing Systems Review and Tests and Measures -- Chapter 13: The SOAP Note: Stating the Problem -- Chapter 14: The SOAP Note: Writing Subjective (S), Includingthe Review of Systems -- Chapter 15: The SOAP Note: Writing Objective (O) -- Part IV: Documenting the Evaluation/Assessment (A); Chapter 16: Writing the Evaluation/ Assessment (A) -- Chapter 17: Writing the Diagnosis (A: DIAGNOSIS) -- Chapter 18: Writing the Prognosis (A: PROGNOSIS) -- Part V: Documentingthe Plan of Care (P); Chapter 19: Writing Expected Outcomes and Anticipated Goals -- Chapter 20: Documenting the Intervention Plan -- Part VI: Applications ofDocumentation Skills; Chapter 21: Writing the Daily Visit Note -- Chapter 22: The Medicare Therapy Cap, KX Modifiers, and Functional Limitations Reporting (G-Codes) -- Chapter 23: Applications and Variations in Note Writing -- Appendix A: Summary of the Patient/Client Management Note Contents -- Appendix B: Summary of the SOAP Note Contents -- Appendix C: Summary of Contents of the Four Types of Notes -- Appendix D: Tips for Note Writing for Third-Party Payors -- Appendix E: Review of Systems and Systems Review Forms -- Index. |
| 506 ## - RESTRICTIONS ON ACCESS NOTE | |
| Terms governing access | Access restricted to authorized users and institutions. |
| 520 3# - SUMMARY, ETC. | |
| Summary, etc. | 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. |
| 538 ## - SYSTEM DETAILS NOTE | |
| System details note | Mode of access: World Wide Web. |
| 650 #7 - SUBJECT ADDED ENTRY--TOPICAL TERM | |
| Topical term or geographic name entry element | MEDICAL / History. |
| Source of heading or term | bisacsh |
| 9 (RLIN) | 34355 |
| 655 #4 - INDEX TERM--GENRE/FORM | |
| Genre/form data or focus term | Electronic books. |
| 700 1# - ADDED ENTRY--PERSONAL NAME | |
| Personal name | Schlomer, Sara Lynn, |
| Relator term | author |
| 9 (RLIN) | 34356 |
| 856 40 - ELECTRONIC LOCATION AND ACCESS | |
| Uniform Resource Identifier | <a href="https://portal.igpublish.com/iglibrary/search/FADAVISB0000534.html">https://portal.igpublish.com/iglibrary/search/FADAVISB0000534.html</a> |
| 942 ## - ADDED ENTRY ELEMENTS (KOHA) | |
| Koha item type | E-book |
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