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| ผู้แต่ง |
Kettenbach, Ginge | | ชื่อเรื่อง |
Writing patient/client notes [electronic resource] : ensuring accuracy in documentation / Ginge Kettenbach, Sara Lynn Schlomer | | ISBN |
978080365846 | | ISBN |
978080363820 | | พิมพ์ลักษณ์ |
[S.l.] : F.A. Davis Company, 2016 | | เลขเรียก |
615.8/ | | เลขหมู่ |
RM701. | | ครั้งที่พิมพ์ |
5th ed | | ลักษณะทางกายภาพ |
295 p | | หมายเหตุ |
Contents: Writing patient/client notes : ensuring accuracy in documentation
-- Preface
-- Contributors
-- Reviewers
-- Table of Contents
-- Chapter 1: Introduction to Documentation
-- Part I: The Health Record; Chapter 2: Overview of the Health Record
-- Chapter 3: Legal Aspects of the Health Record
-- Chapter 4: Reimbursement
-- Chapter 5: Reviewing the Health Record as a Physical Therapist
-- Part II: Documentation Basics; Chapter 6: Writing in a Health Record -- Chapter 7: Introduction to Note Writing -- Chapter 8: Medical Terminology -- Chapter 9: Using Abbreviations -- Chapter 10: Introduction to Documentation Using the International Classification of Functioning, Disability, and Health (ICF) System -- Part III: Documenting the Examination -- Chapter 11: The Patient/Client Management Format: Writing History, Including the Review of Systems -- Chapter 12: The Patient/Client Management Format: Writing Systems Review and Tests and Measures -- Chapter 13: The SOAP Note: Stating the Problem -- Chapter 14: The SOAP Note: Writing Subjective (S), Includingthe Review of Systems -- Chapter 15: The SOAP Note: Writing Objective (O) -- Part IV: Documenting the Evaluation/Assessment (A); Chapter 16: Writing the Evaluation/ Assessment (A) -- Chapter 17: Writing the Diagnosis (A: DIAGNOSIS) -- Chapter 18: Writing the Prognosis (A: PROGNOSIS) -- Part V: Documentingthe Plan of Care (P); Chapter 19: Writing Expected Outcomes and Anticipated Goals -- Chapter 20: Documenting the Intervention Plan -- Part VI: Applications ofDocumentation Skills; Chapter 21: Writing the Daily Visit Note -- Chapter 22: The Medicare Therapy Cap, KX Modifiers, and Functional Limitations Reporting (G-Codes) -- Chapter 23: Applications and Variations in Note Writing -- Appendix A: Summary of the Patient/Client Management Note Contents -- Appendix B: Summary of the SOAP Note Contents -- Appendix C: Summary of Contents of the Four Types of Notes -- Appendix D: Tips for Note Writing for Third-Party Payors -- Appendix E: Review of Systems and Systems Review Forms -- Index | | หมายเหตุ |
Abstract: 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. Section by section you'll learn how to document clearly and accurately, while exercise by exercise you'll practice mastering every step. | | หัวเรื่อง |
Problems and Exercises | | หัวเรื่อง |
Writing | | หัวเรื่อง |
Physical Therapy Specialty | | หัวเรื่อง |
Physical Therapy Modalities | | หัวเรื่อง |
Medical History Taking | | ผู้แต่งร่วม |
Schlomer, Sara Lynn, author |
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