By Lori Quinn EdD PT, James Gordon EdD PT
Better sufferer administration begins with greater documentation! Documentation for Rehabilitation: A consultant to scientific selection Making in actual Therapy, 3rd Edition indicates the best way to safely rfile remedy growth and sufferer results. Designed to be used via rehabilitation pros, documentation instructions are simply adaptable to diversified perform settings and sufferer populations. sensible examples and perform workouts toughen suggestions and inspire you to use what you’ve realized. Written by means of specialist actual remedy educators Lori Quinn and James Gordon, this booklet will increase your talents in either documentation and scientific reasoning.
- A sensible framework
- Coverage of perform settings contains documentation examples in acute care, rehabilitation, outpatient, domestic care, and nursing houses, in addition to a separate bankruptcy on documentation in pediatric settings.
- Guidelines to systematic documentation describe the way to determine, checklist, degree, and evaluation remedy and remedies ― specifically very important whilst insurance firms require proof of sensible growth to be able to supply compensation.
- Workbook/textbook format makes use of examples and workouts in every one bankruptcy to augment your realizing of concepts.
exhibits easy methods to manage and constitution PT documents, making it more straightforward to rfile useful results in lots of perform settings, and relies at the foreign class for Functioning, incapacity, and health and wellbeing (ICF) version ― the only followed by means of the APTA.
- NEW Standardized final result Measures chapter
- UPDATED content material is in keeping with info from present examine, federal regulations and APTA instructions, together with incorporation of recent terminology from the Guide to actual Therapist 3.0 and ICD-10 coding.
- EXPANDED variety of case examples covers an excellent broader diversity of medical perform areas.
ends up in higher care and sufferer administration by way of aiding you decide the precise end result measures to be used in reviews, re-evaluations, and discharge summaries.
Read or Download Documentation for Rehabilitation - A Guide to Clinical Decision Making PDF
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Extra resources for Documentation for Rehabilitation - A Guide to Clinical Decision Making
3. Describe the Health Insurance Portability and Accountability Act (HIPAA) and the Privacy Rule and discuss the implication for physical therapy documentation. 4. Discuss the importance of appropriately documenting informed consent as part of a physical therapy evaluation. 5. Discuss the three legal reasons why a physical therapist’s documentation may be scrutinized. Documentation as a Legal Record Key Legal Aspects Of Physical Therapy Documentation Documentation in a medical record is a legal document.
Patient suffered a cerebrovascular accident, with resultant hemiplegia of the right upper and lower extremity. The home health aide was instructed in assisting patient to perform active-assistive range of motion exercises, which were straight leg raises and hip abduction in supine. 25 26 Section I Theoretical Foundations and Documentation Essentials Exercise 2-3 People-First Language Therapists should avoid “labeling” patients and should always use people-first language in both oral and written communication.
A patient who is recovering from an ankle injury could overexercise in therapy and reinjure the affected area, for example. Alternatively, a patient who has had a stroke could fall and sustain a fracture during gait training or transfer training. Keeping comprehensive and up-to-date medical records is critical to minimizing liability risk. For example, if a patient has reported an increase in pain during the course of a treatment, the therapist should document the current and previous level of pain, whether the plan of care was altered, and if contact with a physician or other health care professional was made.
Documentation for Rehabilitation - A Guide to Clinical Decision Making by Lori Quinn EdD PT, James Gordon EdD PT