| LEADER 03625nam a22301 i 4500 |
| 001 13399111156 |
| 003 ULIBM |
| 006 m eo d |
| 008 190222s2016 ob 000 0 eng |
| 020 ^a978080365846 |
| 020 ^a978080363820 |
| 041 0 ^aen |
| 050 00 ^aRM701. |
| 082 00 ^a615.8/ |
| 100 1 ^aKettenbach, Ginge |
| 245 10 ^aWriting patient/client notes ^h[electronic resource] :^bensuring accuracy in documentation /^cGinge Kettenbach, Sara Lynn Schlomer |
| 250 ^a5th ed |
| 260 ^a[S.l.] :^bF.A. Davis Company,^c2016 |
| 300 ^a295 p |
| 504 ^aIncludes bibliographical references and index |
| 505 0 ^aWriting 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 |
| 520 3 ^aDevelop 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. |
| 650 ^a Problems and Exercises |
| 650 ^a Writing |
| 650 ^a Physical Therapy Specialty |
| 650 ^a Physical Therapy Modalities |
| 650 ^a Medical History Taking |
| 700 ^a Schlomer, Sara Lynn,^eauthor |
| 856 ^u https://portal.igpublish.com/iglibrary/search/FADAVISB0000534.html |
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