Description
Build your documentation skills—and your confidence. Step by step, this text/workbook introduces you to the importance of documentation and shows you how to develop and write a proper and defensible note. You’ll learn how to provide the proper documentation to assure all forms of reimbursement (including third party) for your services. You’ll also explore issues of patient confidentiality, HIPAA requirements, and the ever-increasing demands of legal and ethical practice in a litigious society.
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Bircher (physical therapist assistant program, San Juan College) presents a textbook for physical therapist assistant students that describes documentation tasks, the importance of quality documentation, and how to produce documentation that fulfills the needs of the patient, facility, and third-party payers, as well as related legal and ethical issues. She covers content and organization, patient management and documentation responsibilities, the SOAP (subjective, objective, assessment, and plan) note, and how documentation relates to patient issues. This edition has new chapters on related reimbursement issues and the impact of the World Health Organization's International Classification of Functioning, Disability, and Health on documentation and reimbursement; expanded coverage of electronic documentation; updated terminology that incorporates recent guidelines from the American Physical Therapy Association's Guide to Physical Therapy Practice; and updated reimbursement requirements, standards of care, and coding regulations. Annotation ©2013 Book News, Inc., Portland, OR (booknews.com)
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