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.
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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.