Documentation for Physical Therapist Practice: A Clinical Decision Making Approach: A Clinical Decision Making Approach

by Jacqueline A. Osborne

Overview

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 utilizes a practical clinical decision making approach and applies this framework to all aspects of documentation. This text emphasizes how the common and standard language of the Guide to Physical Therapist Practice and the International Classification of Functioning, Disability, and Health (ICF) model can be integrated with a physical therapist’s clinical reasoning process and a physical therapist assistant’s skill set to produce successful documentation. Includes content on documentation formations: Initial Evaluations, Re-examination Notes, Daily Notes, Conclusion of the Episode of Care Summaries, Home Exercise Program Reviews all the important issues related to style, types of documentation, and utilization of documentation Covers documentation relevant in different settings (inpatient, home health, skilled nursing facility, outpatient) Helps students learn how to report findings and demonstrate an appropriate interpretation of results Includes up-to-date information in line with APTA Guidelines for Defensible Documentation, World Health Organization, International Classification of Functioning Disability and Health Mode, and Medicare Reviews electronic documentation, ICD-9, ICD-10, and CPT codes Includes important chapters on Interprofessional Communication, Legal Aspects, Principles of Measurement

Product Details

ISBN-13:	9781284034226
Publisher:	Jones & Bartlett Learning
Publication date:	08/17/2015
Edition description:	New Edition
Pages:	262
Product dimensions:	8.40(w) x 10.80(h) x 0.80(d)

About the Author

Jacqueline A. Osborne, PT, DPT, GCS, CEEAA is the Director of the Geriatric Residency Program, at Brooks Rehabilitation, a non-profit rehabilitation system in Jacksonville, Florida. In addition to this role, she maintains a clinical practice at Brooks Rehabilitation and serves the American Physical Therapy Association (APTA), the American Board of Physical Therapy Specialties (ABPTS), the American Board of Physical Therapy Residency and Fellowship Education (ABPTRFE), the Florida Physical Therapy Association (FPTA), and the Florida Injury Prevention Advisory Council (FIPAC) as a member of a variety of workgroups and taskforces. Dr. Osborne received a Bachelor of Science degree in Business Administration with a concentration in Operations Management from the University of Delaware in 2000 and a Doctor of Physical Therapy Degree from Beaver College (now Arcadia University) in Glenside, Pennsylvania in 2003. She obtained Board Certification in the area of Geriatric Physical Therapy from the American Board of Physical Therapy Specialties in 2007. She also obtained the credential of Certified Exercise Expert for Aging Adults (CEEAA) from the Section on Geriatrics (now the Academy of Geriatric Physical Therapy) of the American Physical Therapy Association in 2012. Dr. Osborne has a passion of for the care of older adults. She is an advocate for this group in many ways. One way that she works on behalf of older adults on routine basis, however, is through her clinical documentation. There is little more valuable than obtaining needed resources known to benefit patients or clients because of successful documentation! With this text, she hopes to share an approach to documentation rooted in clinical decision-making that will continuously serve as an adjunct to clinicians to advocate for patients and clients in clinical practice.

Table of Contents

Chapter 1 Documentation: An Essential Element of Physical Therapy Practice
Chapter 2 Utilizing the International Classification of Functioning, Disability and Health (ICF) Model in Physical Therapy Documentation
Chapter 3 Documenting the Initial Examination
Chapter 4 Writing Daily Notes
Chapter 5 Documenting the Home Exercise Program
Chapter 6 Documenting Progress
Chapter 7 Conclusion of the Episode of Care
Chapter 8 Principles of Measurement in Documentation
Chapter 9 Interprofessional Communication
Chapter 10 Electronic Health Records: The Medium for Documentation
Chapter 11 The Impact of Health Care Reform on Physical Therapy Documentation
Chapter 12 Legal Considerations in Physical Therapy Documentation