By Wendy Bircher PT EdD
How vital is documentation? Very! actual Therapist Assistants needs to supply the correct documentation to guarantee all varieties of compensation (including 3rd get together) for his or her providers. And, acceptable documentation additionally addresses problems with sufferer confidentiality, HIPAA requisites, and the ever-increasing calls for of criminal and moral perform in a litigious society. construct your scholars documentation abilities and their self belief, step-by-step, with the assistance and perform they ll locate within the third variation. They ll be ready to meet the technological demanding situations of today...and the following day.
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Extra resources for Lukan's Documentation for Physical Therapist Assistants
RECERTIFICATION N/A DC FROM 15. PHYSICIAN’S SIGNATURE 16. DATE THROUGH N/A 17. ON FILE (Print/type physician’s name) 18. ) 19. SIGNATURE (or name of professional, including prof. designation) 20. DATE 21. CONTINUE SERVICES OR DC SERVICES 22. ) 22. SERVICE DATES FROM Form CMS-701(11-91) Figure 2—11 Medicare Recertification Form CMS-701. THROUGH 27 02Bircher(F)-02 28 8/10/07 3:33 PM Page 28 PART ONE ■ Why is Documentation Important? affect his or her ability to fully understand the PTA’s exercise instructions.
02Bircher(F)-02 8/10/07 3:33 PM Page 21 CHAPTER 2 ■ Documentation Content Physical Therapy Daily Progress Notes MODALITIES: DATE/Initials DATE/Initials DATE/Initials DATE/Initials DATE/Initials DATE/Initials Hot Pack/Cold Packs Massage/Ice Massage Electrical Stimulation Traction Ultrasound Kinetic Activity Therapeutic Exercise Neuromuscular Re-ed Functional Activities Training in ADL’s Serial Casting Gait Training Orthotics/Prosthetics Train. Wound Care Whirlpool Therapy Conference Consultation Other Comments: Date Assessment: Goals: Plan: Treatment Diagnosis: Figure 2—5B (Name) Date (Name) Date (Name) Date Physical therapy progress note forms that combine presentation styles.
Ple of each section of the SOAP note. It is one of the simplest documentation methods used and will be discussed, in detail, in Chapters 3 through 6. ORGANIZATION OF THE DOCUMENTATION CONTENT Clinical facilities often differ in the way their documentation is organized and sequenced within the evaluation reports and progress notes. A study of some examples of content organization models reveals a common logic to the sequencing of the information. 02Bircher(F)-02 30 8/10/07 3:33 PM Page 30 PART ONE ■ Why is Documentation Important?
Lukan's Documentation for Physical Therapist Assistants by Wendy Bircher PT EdD