New to this edition
- NEW Standardized Outcome Measures chapter
leads to better care and patient management by helping you select the right outcome measures for use in evaluations, re-evaluations, and discharge summaries.
- UPDATED content is based on data from current research, federal policies and APTA guidelines, including incorporation of new terminology from the Guide to Physical Therapist 3.0 and ICD-10 coding.
- EXPANDED number of case examples covers an even broader range of clinical practice areas.
Author Information
By Lori Quinn, EdD, PT, Associate Professor of Movement Science and Kinesiology
Director, Neurorehabilitation Research Lab
Teachers College, Columbia University and James Gordon, EdD, PT, FAPTA, Professor and Associate Dean
Division of Biokinesiology and Physical Therapy at the Herman Ostrow School of Dentistry
University of Southern California
I: THEORETICAL FOUNDATIONS
1. Disablement Models, ICF Framework and Clinical Decision Making
2. Essentials of Documentation
3. Legal Aspects of Documentation
4. Standardized Outcome Measures NEW!
5. Payment Policy and Coding
6 Electronic Medical Records
II: COMPONENTS OF PHYSICAL THERAPY DOCUMENTATION
7. Clinical Decision Making and the Initial Evaluation Format
8. Documenting Reason for Referral: Health Condition and Participation
9. Documenting Activities
10. Documenting Impairments
11. Document the Assessment: Summary and Diagnosis
12. Developing and Documenting Effective Goals
13. Documenting the Plan of Care
14. Documenting Session Notes and Progress Notes Using a Modified SOAP Note Format
15. Special Formats: Documenting Screenings, Discharge Summaries, Letters and Patient Education Materials
16. Documentation in Pediatrics
References
Appendix A: Guidelines: Physical Therapy Documentation of Patient/Client Management
Appendix B: Rehabilitation Abbreviations
Appendix C: Answers to Exercises
Appendix D: Documentation Review Sample Checklist
Appendix E: Strength and Range of Motion Forms
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