Documentation for Rehabilitation A Guide to Clinical Decision Making 2nd Edition by Lori Quinn, James Gordon ISBN 978-1416062219 1416062211
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Product details:
ISBN 10: 1416062211
ISBN 13: 978-1416062219
Author: Lori Quinn, James Gordon
Ensure confident clinical decisions and maximum reimbursement in a variety of practice settings such as acute care, outpatient, home care, and nursing homes with the only systematic approach to documentation for rehabilitation professionals! Revised and expanded, this hands-on textbook/workbook provides a unique framework for maintaining evidence of treatment progress and patient outcomes with a clear, logical progression. Extensive examples and exercises in each chapter reinforce concepts and encourage you to apply what you’ve learned to realistic practice scenarios.
Table of contents:
SECTION I: Theoretical Foundations and Documentation Essentials
1. Disablement Models, ICF Framework, and Clinical Decision Making
2. Essentials of Documentation
3. Legal Aspects of Documentation
4. Clinical Decision Making and the Initial Evaluation Format
SECTION II: Components of Physical Therapy Documentation
5. Documenting Reason for Referral: Background Information and Health Condition
6. Documenting Reason for Referral: Participation and Social History
7. Documenting Activities
8. Documenting Impairments in Body Structure and Function
9. Documenting the Assessment: Summary and Diagnosis
10. Documenting Goals
11. Documenting the Plan of Care
12. Treatment Notes and Progress Notes Using a Modified SOAP Format
SECTION III: Additional Documentation Formats
13. Specialized Documentation
14. Documentation in Pediatrics — Lori Quinn and Agnes McConlogue
15. Payment Policy and Coding — Helene M. Fearon, Stephen M. Levine, and Lori Quinn
16. Computerized Documentation — Janet Herbold
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Tags: Lori Quinn, James Gordon, Documentation for Rehabilitation, A Guide, Clinical Decision