Writing Patient/Client Notes
Writing Patient/Client Notes

Author: Ginge Kettenbach

Publisher: F.A. Davis

Published: 2016-05-11

Total Pages: 295

ISBN-13: 080365846X

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Develop all of the skills you need to write clear, concise, and defensible patient/client care notes using a variety of tools, including SOAP notes. This is the ideal resource for any health care professional needing to learn or improve their skills—with simple, straight forward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management and WHO’s ICF model.

Writing S.O.A.P. Notes
Writing S.O.A.P. Notes

Author: Ginge Kettenbach

Publisher: F. A. Davis Company

Published: 1990

Total Pages: 164

ISBN-13:

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-- Chapter on the development and use of forms and documentation-- Coverage of computerized documentation-- Thorough updating, including a discussion of the managed care environment and Medicare-- Additional exercises and examples-- Perforated worksheets-- Basic note-writing rules, including the POMR method, are reviewed-- Examples provided of both correct and incorrect note writing

Writing SOAP Notes
Writing SOAP Notes

Author: Ginge Kettenbach

Publisher: F A Davis Company

Published: 2003

Total Pages: 215

ISBN-13: 9780803608368

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Ginge Kettenbach's workbook leads you through the process of learning two different styles of documentation: SOAP (Subjective/Objective/Assessment/Plan) notes and the Patient/Client Management format. This updated 3rd edition includes hands-on exercises and examples to help you sharpen the writing skills that you will need to prepare clear, concise, and accurate medical documentation. Worksheets at the end of each note section further strengthen your writing skills on the information you have just learned. Explanations of documentation that are consistent with the APTA's Guide to Physical Therapist Practice are given for all decisions. Book jacket.

The Rehabilitation Specialist's Handbook
The Rehabilitation Specialist's Handbook

Author: Jules M. Rothstein

Publisher: F. A. Davis Company

Published: 1998

Total Pages: 0

ISBN-13: 9780803600478

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A reference handbook for rehabilitation specialists, featuring many two-color illustrations, tables, and charts. Contains chapters on musculoskeletal, visceral, pulmonary, and vascular anatomy, as well as neuroanatomy, kinesiology, psychology, massage, general medicine, burns, and AIDS, plus useful phrases in Spanish, Italian, French, and German. This second edition is smaller (4.75x8") yet contains one- third more material, with new sections on the ADA, geriatrics, outcome measures, and pharmacology, and offer features enhancing usability, such as section tables of contents and more information on references. Annotation copyrighted by Book News, Inc., Portland, OR

Model Rules of Professional Conduct
Model Rules of Professional Conduct

Author: American Bar Association. House of Delegates

Publisher: American Bar Association

Published: 2007

Total Pages: 216

ISBN-13: 9781590318737

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The Model Rules of Professional Conduct provides an up-to-date resource for information on legal ethics. Federal, state and local courts in all jurisdictions look to the Rules for guidance in solving lawyer malpractice cases, disciplinary actions, disqualification issues, sanctions questions and much more. In this volume, black-letter Rules of Professional Conduct are followed by numbered Comments that explain each Rule's purpose and provide suggestions for its practical application. The Rules will help you identify proper conduct in a variety of given situations, review those instances where discretionary action is possible, and define the nature of the relationship between you and your clients, colleagues and the courts.

The Clinical Documentation Sourcebook
The Clinical Documentation Sourcebook

Author: Donald E. Wiger

Publisher: John Wiley & Sons

Published: 2010-02-02

Total Pages: 338

ISBN-13: 0470527781

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All the forms, handouts, and records mental health professionals need to meet documentation requirements–fully revised and updated The paperwork required when providing mental health services continues to mount. Keeping records for managed care reimbursement, accreditation agencies, protection in the event of lawsuits, and to help streamline patient care in solo and group practices, inpatient facilities, and hospitals has become increasingly important. Now fully updated and revised, the Fourth Edition of The Clinical Documentation Sourcebook provides you with a full range of forms, checklists, and clinical records essential for effectively and efficiently managing and protecting your practice. The Fourth Edition offers: Seventy-two ready-to-copy forms appropriate for use with a broad range of clients including children, couples, and families Updated coverage for HIPAA compliance, reflecting the latest The Joint Commission (TJC) and CARF regulations A new chapter covering the most current format on screening information for referral sources Increased coverage of clinical outcomes to support the latest advancements in evidence-based treatment A CD-ROM with all the ready-to-copy forms in Microsoft® Word format, allowing for customization to suit a variety of practices From intake to diagnosis and treatment through discharge and outcome assessment, The Clinical Documentation Sourcebook, Fourth Edition offers sample forms for every stage of the treatment process. Greatly expanded from the Third Edition, the book now includes twenty-six fully completed forms illustrating the proper way to fill them out. Note: CD-ROM/DVD and other supplementary materials are not included as part of eBook file.

The Adult Psychotherapy Progress Notes Planner
The Adult Psychotherapy Progress Notes Planner

Author: Arthur E. Jongsma, Jr.

Publisher: John Wiley & Sons

Published: 2014-01-27

Total Pages: 528

ISBN-13: 1118418727

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Save hours of time-consuming paperwork with the bestselling treatment planning system The Adult Psychotherapy Progress Notes Planner, Fifth Edition contains complete prewritten session and patient presentation descriptions for each behavioral problem in The Complete Adult Psychotherapy Treatment Planner, Fifth Edition. The prewritten progress notes can be easily and quickly adapted to fit a particular client need or treatment situation. Saves you hours of time-consuming paperwork, yet offers the freedom to develop customized progress notes Organized around 43 behaviorally based presenting problems, including depression, intimate relationship conflicts, chronic pain, anxiety, substance abuse, borderline personality, and more Features over 1,000 prewritten progress notes (summarizing patient presentation, themes of session, and treatment delivered) Provides an array of treatment approaches that correspond with the behavioral problems and DSM-5TM diagnostic categories in The Complete Adult Psychotherapy Treatment Planner, Fifth Edition Offers sample progress notes that conform to the requirements of most third-party payors and accrediting agencies, including CARF, The Joint Commission (TJC), COA, and the NCQA Identifies the latest evidence-based care treatments with treatment language following specific guidelines set by managed care and accrediting agencies

Encyclopedia & Dictionary of Medicine, Nursing, and Allied Health
Encyclopedia & Dictionary of Medicine, Nursing, and Allied Health

Author: Marie T. O'Toole

Publisher:

Published: 2003

Total Pages: 2356

ISBN-13:

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The Miller-Keane Encyclopedia & Dictionary of Medicine, Nursing, & Allied Health is highly regarded for its accuracy, the clinical usefulness of its entries, and its multidisciplinary approach that encompasses current topics across the entire spectrum of health care. Trademark features include comprehensive encyclopedic entries, portable size, soft cover, printed thumb tabs, unique "Windows" essays, and a color A&P atlas. Organized by major terms with related terms defined as subentries, Miller-Keane's organization provides easy access to information on a variety of closely related topics in one location. Encyclopedic entries are included for significant topics, such as diseases, disorders, or conditions. These encyclopedic entries include the definition along with a concise overview of the most important information related to Symptoms, Treatment, Patient Care, Prevention, etc. Miller-Keane also includes an extensive list of appendices. Dorland's spellchecker software and a companion Evolve website supplement this edition making it a powerful tool to building and using a medical vocabulary for all health professionals.

Note Designer
Note Designer

Author: Patricia C Baldwin

Publisher: Mindhabits Incorporated

Published: 2016-03-23

Total Pages: 76

ISBN-13: 9780995063402

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This book provides step-by-step guidelines, tips, and instruction on how to create and write psychotherapy treatment notes. Information and guidance are provided on how to write a treatment intake report, treatment progress notes, and termination summary. A number of sample notes, reports and templates are provided. The book also includes hundreds of representative statements for therapists to use in the design of their own psychotherapy progress notes. A valuable resource for experienced mental health professionals and trainees alike, from the creator of Note Designer therapy note-writing software. ""A time-saving reference to capture the essence and the methods of professional note writing for psychotherapists. Easy to apply and great to keep close-by when writing reports and progress notes."" --Alexandre Smith-Peter, Psy.D. candidate

The Counselor's Steps for Progress Notes
The Counselor's Steps for Progress Notes

Author: Rhonda Sutton

Publisher: Createspace Independent Publishing Platform

Published: 2015-06-21

Total Pages: 156

ISBN-13: 9781514643587

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Dr. Rhonda Sutton's second edition of the straightforward guide to progress notes includes additional examples, information, documentation, and clinical language that expands on the utility and readability of the first book. Additional case studies provide examples of how to use the STEPs to format notes. New chapters include information on clinical language and documentation. This book covers everything about progress notes, from how to write them, to how to store them, and even what to do when someone requests to them. In addition, clinical terms and abbreviations are included as well as suggestions for other clinical documentation such as termination letters, privacy statements, and professional disclosure statements. Suited for all types of mental health clinicians, this book will help therapists improve upon their progress notes and other forms of clinical documentation.