Description
Erickson (physical therapy clinical education, West Virginia U.), Utzman, and McKnight describe clinical documentation in physical therapy. They integrate the mechanics of writing and basic documentation elements with contemporary concepts and use the International Classification of Functioning, Disability, and Health disablement framework for the integration of function, results of interventions, and patient improvement. They use the subjective, objective, assessment, and plan (SOAP) structure, but emphasize the need for high-quality documentation content, as well as the integration of evidence-based practice. They describe reasons for documentation; formats; rules for writing in medical records; documenting patient/client management, histories and interviews, and objective information; writing the assessment and treatment plan; interim documentation; patient outcomes and discharge summaries; and documentation and reimbursement. This edition has sections on electronic documentation, discussion of research evidence, templates, a chapter on ethical and regulatory issues, and more on contemporary concepts like skilled services and medical necessity. Annotation ©2013 Book News, Inc., Portland, OR (booknews.com)
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Complete and accurate documentation is one of the most essential skills for a physical therapist to develop and use effectively. Necessary for both new and experienced practitioners, the new and updated Second Edition of Physical Therapy Documentation: From Examination to Outcome will teach and explain physical therapy documentation from A to Z. Physical Therapy Documentation, Second Edition provides individuals with the knowledge and skills for documenting physical therapy services. The text begins with several chapters of background information that give the rationale for quality documentation. Physical Therapy Documentation, Second Edition provides the physical therapist's ethical responsibility for quality record keeping. The mechanics of note writing are delivered in a manner friendly to those who are learning the basic elements of documentation. Mia Erickson, Ralph Utzman, and Rebecca McKnight also include chapters on professional responsibilities and reimbursement issues commonly associated with documentation that are important to physical therapists. Each chapter includes examples and opportunities for practice covering a variety of physical therapy patients and settings.Features in the Second Edition:'Multiple sections covering electronic documentation, including the positive and negative aspects and common pitfalls. 'Use of research evidence on integrating and documenting tests and measures is provided in the mechanics of note writing.'Multiple templates for documenting initial notes, interim notes, and discharge summaries are given but deviation from these templates, such as during use of the electronic record, are also discussed.'Ethical and regulatory issues related to documentation of physical therapy care.'Increased emphasis on documenting contemporary concepts such as skilled services and medical necessity.In keeping with the familiarity of the basic SOAP structure, Physical Therapy Documentation, Second Edition breaks down the components of the A and P portions of the note; however, information is provided that allows readers to create documentation that blends these sections into a 'Plan of Care.'Physical Therapy Documentation: From Examination to Outcome, Second Edition provides physical therapy students, educators, and clinicians with a valuable reference tool for documentation within contemporary physical therapy practice.
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