[PDF] Documentation For Physical Therapist Practice A Clinical Decision Making Approach eBook
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Documentation for Physical Therapist Practice: A Clinical Decision Making Approach provides the framework for successful documentation. It is synchronous with Medicare standards as well as the American Physical Therapy Association’s recommendations for defensible documentation. It identifies documentation basics which can be readily applied to a broad spectrum of documentation formats including paper-based and electronic systems. This key resource skillfully explains how to document the interpretation of examination findings so that the medical record accurately reflects the evidence. In addition, the results of consultation with legal experts who specialize in physical therapy claims denials will be shared to provide current, meaningful documentation instruction.
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Better patient management starts with better documentation! Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy, 3rd Edition shows how to accurately document treatment progress and patient outcomes. Designed for use by rehabilitation professionals, documentation guidelines are easily adaptable to different practice settings and patient populations. Realistic examples and practice exercises reinforce concepts and encourage you to apply what you’ve learned. Written by expert physical therapy educators Lori Quinn and James Gordon, this book will improve your skills in both documentation and clinical reasoning. A practical framework shows how to organize and structure PT records, making it easier to document functional outcomes in many practice settings, and is based on the International Classification for Functioning, Disability, and Health (ICF) model — the one adopted by the APTA. Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, and nursing homes, as well as a separate chapter on documentation in pediatric settings. Guidelines to systematic documentation describe how to identify, record, measure, and evaluate treatment and therapies — especially important when insurance companies require evidence of functional progress in order to provide reimbursement. Workbook/textbook format uses examples and exercises in each chapter to reinforce your understanding of concepts. 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.
In this textbook, Quinn and Gordon provide a general approach to documentation that can be adapted to different settings, for physical therapy students and professionals. They emphasize the concept that clinical reasoning is reflected in documentation (and vice versa) and that documentation is a framework for clinical decision making. They cover each documentation component, and examples and exercises that relate to areas such as rehabilitation, women's health, health and wellness, orthopedics, and acute care. This edition has been revised and expanded and includes new chapters on payment policy and coding, legal aspects, pediatrics, and computerized documentation, and incorporates the International Classification of Functioning, Disability, and Health model.
From common to complex, thirteen real-life case studies represent a variety of practice settings and age groups. Identify, research, and assess the pathologies and possible treatments. Photographs of real therapists working with their patients bring concepts to life. Reviewed by 16 PT and PTA experts, this comprehensive resource ensures you are prepared to confidently make sound clinical decisions.
Better patient management starts with better documentation! Documentation for Rehabilitation, 4th Edition demonstrates how to accurately document treatment progress and patient outcomes using a framework for clinical reasoning based on the International Classification for Functioning, Disability, and Health (ICF) model adopted by the American Physical Therapy Association (APTA). The documentation guidelines in this practical resource are easily adaptable to different practice settings and patient populations in physical therapy and physical therapy assisting. Realistic examples and practice exercises reinforce the understanding and application of concepts, improving skills in both documentation and clinical reasoning. Workbook/textbook format with examples and exercises in each chapter helps reinforce understanding of concepts. Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, nursing homes, pediatrics, school, and community settings. Case examples for a multitude of documentation types include initial evaluations, progress notes, daily notes, letters to insurance companies, Medicare documentation, and documentation in specialized settings. NEW! Movement Analysis - Linking Activities and Impairments content addresses issues related to diagnosis. NEW! An eBook version, included with print purchase, provides access to all the text, figures and references, with the ability to search, customize content, make notes and highlights, and have content read aloud. Updated case examples provide clinical context for patient documentation. Revised content, including updated terminology from the latest updates to the Guide to Physical Therapist Practice, provides the most current information needed to be an effective practitioner. Updated references ensure content is current and applicable for today's practice.
Clinical reasoning is an essential non-negotiable element for all health professionals. The ability of the health professional to demonstrate professional competence, compassion, and accountability depend on a foundation of sound clinical reasoning. The clinical reasoning process needs to bring together knowledge, experience, and understanding of people, the environment, and organizations along with a strong moral compass in making sound decisions and taking necessary actions. While clinical reasoning and the role of mentors has been a focus of the continued growth and development of residency programs in physical therapy, there is a critical need to have a broader, in-depth look at how educators across academic and clinical settings intentionally facilitate the development of clinical reasoning skills across one’s career. Clinical Reasoning and Decision Making in Physical Therapy: Facilitation, Assessment, and Implementation fills this need by providing a comprehensive and in-depth focus on development of the patient-client management skills of clinical reasoning and clinical decision-making. It takes into account teaching and learning strategies, assessment, and technological applications across the continuum from novice to residents/fellows-in-training, along with academic and clinical faculty for both entry-level and specialist practice. Drs. Gina Maria Musolino and Gail Jensen have designed this comprehensive resource with contributions from professional colleagues. The text centers on life-long learning by encouraging the development of clinical reasoning abilities from professional education through residency education. The aim and scope of the text is directed for physical therapy education, to enhance clinical reasoning and clinical decision-making for developing professionals and post-professionals in both clinical and academic realms, and for the development of clinical and academic faculty. Clinical Reasoning and Decision Making in Physical Therapy uniquely offers both evidence-based approaches and pragmatic consultation from award-winning authors with direct practice experiences developing and implementing clinical reasoning/clinical decision-making in practice applications for teaching students, residents, patients, and clinical/academic faculty in classrooms, clinics, and through simulation and telehealth. Clinical Reasoning and Decision Making in Physical Therapy is the first of its kind to address this foundational element for practice that is key for real-world practice and continuing competence as a health care professional. Physical therapy and physical therapist assistant students, faculty, and clinicians will find this to be an invaluable resource to enhance their clinical reasoning and decision making abilities.
Documentation for Physical Therapist Practice: A Clinical Decision Making Approach provides the framework for successful documentation. It is synchronous with Medicare standards as well as the American Physical Therapy Association’s recommendations for defensible documentation. It identifies documentation basics which can be readily applied to a broad spectrum of documentation formats including paper-based and electronic systems. This key resource skillfully explains how to document the interpretation of examination findings so that the medical record accurately reflects the evidence. In addition, the results of consultation with legal experts who specialize in physical therapy claims denials will be shared to provide current, meaningful documentation instruction.
Publisher's Note: Products purchased from Third Party sellers are not guaranteed by the publisher for quality, authenticity, or access to any online entitlements included with the product. Clear, concise, and simple to follow—everything you need to master the documentation process quickly and easily Communicating Clinical Decision Making Through Documentation is the top choice for professionals and students seeking complete coverage of the documentation process including billing and coding. It shows how to ensure every service rendered and billed is supported by showing what to document, how to do it, and why it is so important. This text includes a refreshing student-friendly approach to the topic. You will find an abundance of cases portraying real-life case scenarios and it delivers must-know information on writing patient/client care notes, incorporating document guidelines, documenting clinical decision making (includes evidence-based practice), and performing billing and coding tasks. With Communicating Clinical Decision Making Through Documentation, you’ll effectively maintain and organize records, record appropriate information, and receive proper payment based on the documentation content. A to Z coverage of physical therapy documentation, including: Documentation Standards and Guidelines Medicare Home Health Electronic Medical Records (EMR) International Classification of Functioning (ICF) Model and Application Pediatrics Legal Issue Utilization Review & Management Skilled Nursing Facilities Sample Documentation Content Initial Examination and Evaluation Criteria Continuum of Care Content and Goal Writing Exercises Documentation Aspects of Supervising PTAs Abbreviations Payment ICD-10 and CPT Codes and Application Chapter Review Questions Content Principles
Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. The new Second Edition of Documentation Basics: A Guide for the Physical Therapist Assistant continues the path of teaching the student and clinician documentation from A to Z.