Fourth Edition, is the only text to integrate coverage of the legal responsibilities of rehabilitation professionals with basic, essential advice on how to effectively document patient care activities from intake through discharge. This resource thoroughly covers the basics of documentation and includes many exemplars, cases, and forms, as well as a sample abbreviations used in rehabilitation settings. This book covers all the bases from ethics, to practical aspects of patient care documentation, to relevant and salient legal implications and illustrative case examples that will help students excel in practice.
Because communication among health care professionals can mean the difference between patient life and death, clear and effective patient care documentation is as important as the delivery of care itself. The rehabilitation professional faces formidable documentation responsibilities. Patient care documentation created by the rehabilitation professional must be accurate, comprehensive, concise, objective, and timely. In an interdisciplinary health care environment, documentation must also be expeditiously communicated to other professionals on the health care team.
Pamphlet is a succinct statement of the ethical obligations and duties of individuals who enter the nursing profession, the profession's nonnegotiable ethical standard, and an expression of nursing's own understanding of its commitment to society. Provides a framework for nurses to use in ethical analysis and decision-making.
This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.
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.
Newly updated and revised, Physical Therapy Documentation: From Examination to Outcome, Third Edition provides physical therapy students, educators, and clinicians with essential information on documentation for contemporary physical therapy practice. Complete and accurate documentation is one of the most essential skills for physical therapists. In this text, authors Mia L. Erickson, Rebecca McKnight, and Ralph Utzman teach the knowledge and skills necessary for correct documentation of physical therapy services, provide guidance for readers in their ethical responsibility to quality record-keeping, and deliver the mechanics of note writing in a friendly, approachable tone. Featuring the most up-to-date information on proper documentation and using the International Classification of Functioning, Disabilities, and Health (ICF) model as a foundation for terminology, the Third Edition includes expanded examples across a variety of practice settings as well as new chapters on: Health informatics Electronic medical records Rules governing paper and electronic records Billing, coding, and outcomes measures Included with the text are online supplemental materials for faculty use in the classroom. An invaluable reference in keeping with basic documentation structure, Physical Therapy Documentation: From Examination to Outcome, Third Edition is a necessity for both new and seasoned physical therapy practitioners.
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.
Although it is the least noticed by patients, effective documentation is one of the most critical skills that speech-language pathologists must learn. With that in mind, Documentation and Reimbursement for Speech-Language Pathologists: Principles and Practiceprovides a comprehensive guide to documentation, coding, and reimbursement across all work settings. The text begins with section 1 covering the importance of documentation and the basic rules, both ethical and legal, followed by an exploration of the various documentation forms and formats. Also included are tips on how to use electronic health records, as well as different coding systems for diagnosis and for procedures, with an emphasis on the link between coding, reimbursement, and the documentation to support reimbursement. Section 2 explains the importance of focusing on function in patient-centered care with the ICF as the conceptual model, then goes on to cover each of the types of services speech-language pathologists provide: evaluation, treatment planning, therapy, and discharge planning. Multiple examples of forms and formats are given for each. In section 3, Nancy Swigert and her expert team of contributors dedicate each chapter to a work setting in which speech-language pathologists might work, whether adult or pediatric, because each setting has its own set of documentation and reimbursement challenges. And since client documentation is not the only kind of writing done by speech-language pathologists, a separate chapter on “other professional writing” includes information on how to write correspondence, avoid common mistakes, and even prepare effective PowerPoint presentations. Each chapter in Documentation and Reimbursement for Speech-Language Pathologists contains activities to apply information learned in that chapter as well as review questions for students to test their knowledge. Customizable samples of many types of forms and reports are also available. Included with the text are online supplemental materials for faculty use in the classroom. Documentation and Reimbursement for Speech-Language Pathologists: Principles and Practice is the perfect text for speech-language pathology students to learn these vital skills, but it will also provide clinical supervisors, new clinicians, and speech-language pathologists starting a private practice or managing a department with essential information about documentation, coding, and reimbursement.
Designed to help students become effective, reflective practitioners, this fully updated edition of the most widely used occupational therapy text for the course continues to emphasize the “whys” as well as the “how-tos” of holistic assessment and treatment. Now in striking full color and co-edited by renowned educators and authors Diane Powers Dirette and Sharon Gutman, Occupational Therapy for Physical Dysfunction, Eighth Edition features expert coverage of the latest assessment techniques and most recent trends in clinical practice. In addition, the book now explicitly integrates “Frames of Reference” to help students connect theories to practice and features a new six-part organization, thirteen all-new chapters, new pedagogy, and more.
A newly updated, user-friendly resource for occupational therapy assistant students and new practitioners, Developing Clinical Competence: A Workbook for the OTA, Second Edition assists readers in developing practical problem-solving and “‘real-life”’ skills essential for fieldwork and clinical practice. Maintaining the easy-to-read workbook format from the First Edition, this book is filled with learning activities, worksheets, and detailed answer explanations, as well as expanded chapter content and revised references. Marie J. Morreale breaks down competencies into step-by-step units to allow for independent study. With multiple choice, matching, true/false, and fill-in-the-blanks questions; case studies; vignettes; and experiential activities, this Second Edition presents helpful tips in their most useful format. Guiding the reader through occupational therapy clinical decision making, professional conduct, and meeting standards of care for various practice areas, each chapter is fully independent and can be read in the order most conducive to the reader’s individual learning needs. This text can help readers measure attainment of knowledge and skills when preparing for fieldwork, the national certification exam, or transitioning to entry-level practice. New for the Second Edition: Fundamental topics including effective communication, assessment of client function, safety, supervision, documentation, group process, and department management Additional questions regarding behavioral health and pediatric practice Expanded content for professionalism, ethics, cultural sensitivity, and interventions to support occupations Topics such as wheeled mobility, hand function development, infection control, feeding/eating, wound care basics, quality improvement, and more Added content regarding the American Occupational Therapy Association documents, evidence-informed practice, advocacy, chronic conditions, and new trends Incorporated concepts and principles from the Occupational Therapy Practice Framework: Domain and Process, Fourth Edition Included with the text are online supplemental materials for faculty use in the classroom. Addressing fundamental areas of occupational therapy practice for a wide variety of conditions, situations, and practice settings, Developing Clinical Competence: A Workbook for the OTA, Second Edition includes helpful hints and practical clinical tips to help the OTA implement appropriate interventions and communicate more effectively.
