This is the ideal resource for any health care professional needing to learn or improve their skillswith 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 WHOs ICF model.

Table of Contents

• Preface
• Contributors
• Reviewers
• Introduction to Documentation
• The Health Record
• Preface
• Overview of the Health Record
• Legal Aspects of the Health Record
• Reimbursement
• Reviewing the Health Record as a Physical Therapist
• Documentation Basics
• Preface
• Writing in a Health Record
• Introduction to Note Writing
• Medical Terminology
• Worksheet 1: Medical Terminology
• Worksheet 2: Medical Terminology
• Using Abbreviations
• Worksheet 1: Using Abbreviations
• Worksheet 2: Using Abbreviations
• Introduction to Documentation Using the International Classification of Functioning, Disability, and Health (ICF) System
• ICF practice case
• Documenting the Examination
• Preface
• The Patient/Client Management Format: Writing History, Including the Review of Systems
• Exercise: Review of Systems
• Worksheet 1: Writing History
• The Patient/Client Management Format: Writing Systems Review and Tests and Measures
• The Patient/Client Management Note:
• The SOAP Note: Stating the Problem
• The SOAP Note: Writing Subjective (S), Including the Review of Systems
• Exercise: Review of Systems
• Worksheet 1: Writing Subjective, Including Review of Systems
• The SOAP Note: Writing Objective (O)
• Worksheet: The SOAP Note: Writing Objective (O), including Systems Review
• Patient/Client Management Format: Writing the History, Systems Review, and Tests and Measures
• The SOAP Note: Stating the Problem, Subjective (S), and Objective (O), including Systems Review
• Documenting the Evaluation/ Assessment (A)
• Preface
• Writing the Evaluation/ Assessment (A)
• Writing the Diagnosis (A: DIAGNOSIS)
• Writing the Prognosis (A: PROGNOSIS)
• Worksheet 1
• Worksheet 2
• Review Worksheet Patient/Client Managment Format: Writing the Evaluation
• The SOAP Format: Writing the Assessment (A)
• Documenting the Plan of Care (P)
• Preface
• Writing Expected Outcomes and Anticipated Goals
• Expected Outcomes
• Anticipated Goals
• Documenting the Intervention Plan
• worksheet
• The Patient/Client Management Format: Writing the Plan of Care
• The SOAP Note: Writing the Plan (P)
• Applications of Documentation Skills
• Preface
• Writing the Daily Visit Note
• Worksheet
• The Medicare Therapy Cap, KX Modifiers, and Functional Limitations Reporting (G-Codes)
• 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