Documentation for physical therapist assistants

Inside Front Cover
Title Page
Copyright
Dedication
Preface
Reviewers
Acknowledgments
Contents
PART ONE Why Is Documentation Important?
	Chapter 1 Introduction to Documentation
		LEARNING OBJECTIVES
		INTRODUCTION
		DOCUMENTATION AND IT SSIGNIFICANCE
		EVOLUTION OF PT AND PTA RESPONSIBILITIES AND ROLE OF DOCUMENTATION
		THE ROLE OF DOCUMENTATION IN PATIENT CARE
		DOCUMENTATION STANDARDS AND CRITERIA
		SUMMARY
		REFERENCES
		Review Exercises
	Chapter 2 The World Health Organization and the International Classification of Functioning, Disability and Health
		LEARNING OBJECTIVES
		INTRODUCTION
		WHO FAMILY OF INTERNATIONAL CLASSIFICATIONS
		THE ICF FRAMEWORK
		SUMMARY
		REFERENCES
		Review Exercises
		PRACTICE EXERCISES
	Chapter 3 Demystifying the ICD-10 Coding System
		LEARNING OBJECTIVES
		INTRODUCTION
		TRANSITION FROM ICD-9 TO ICD-10
		FUNCTIONAL OUTCOMES AND “G” CODES
		PHYSICIAN QUALITY REPORTING CODING SYSTEM (PQRS)
		PTA INVOLVEMENT
		SUMMARY
		REFERENCES
		Review Exercises
	Chapter 4 Reimbursement Issues Related to Documentation
		LEARNING  OBJECTIVES
		INTRODUCTION
		MANAGED CARE ORGANIZATIONS (MCOs)
		MEDICARE
		MEDICAID
		PROGRAM OF ALL INCLUSIVECARE FOR THE ELDERLY (PACE)
		WORKERS’ COMPENSATION INSURANCE
		OTHER MEDICAL INSURANCE OPTIONS
		HEALTH-CARE REFORM LAW AND THE AFFORDABLE CARE ACT (ACA)
		HEALTH CARE AND POTENTIAL CHANGES TO DOCUMENTATION
		REIMBURSEMENT FOR PT VERSUS PTA STUDENT SERVICES
		SUMMARY
		REFERENCES
		Review Exercises
	Chapter 5 Documentation Content and Organization
		LEARNING OBJECTIVES
		INTRODUCTION
		WHAT IS BEING DOCUMENTED?
		TYPES OF MEDICAL RECORDS
		LOGICAL SEQUENCING OF CONTENT IN THE MEDICAL RECORD
		FORMATS FOR RECORDING CONTENT
		SUMMARY
		REFERENCES
		Review Exercises
		PRACTICE EXERCISES
	Chapter 6 Physical Therapy Patient Management and Documentation Responsibilities
		LEARNING OBJECTIVES
		INTRODUCTION
		FIVE ELEMENTS OF PHYSICAL THERAPY PATIENT MANAGEMENT
		TYPES AND CONTENT OF EXAMINATIONS AND EVALUATIONS
		DOCUMENTATION SPECIFICS
		SUMMARY
		REFERENCES
		Review Exercises
		PRACTICE EXERCISES
PART TWO How Do SOAP Notes Ensure Good Patient Care
	Chapter 7 How Does Documentation Relate to Patient Issues?
		LEARNING OBJECTIVES
		INTRODUCTION
		OUTCOMES ANDTREATMENT
		PATIENT CONFIDENTIALITY ISSUES
		COMMUNICATION GUIDELINES:TELEPHONE REFERRALS
		PROTECTING THE PATIENT
		SUMMARY
		REFERENCES
		Review Exercises
		PRACTICE EXERCISES
	Chapter 8 Your Documentation Related to Legal and Ethical Issues
		LEARNING OBJECTIVES
		INTRODUCTION
		PROFESSIONAL LIABILITY INSURANCE
		LEGAL ISSUES
		ETHICAL ISSUES
		SUMMARY
		REFERENCES
		Review Exercises
		PRACTICE EXERCISES
PART THREE Steps to Documentation
	Chapter 9 Introduction to the SOAP Note
		LEARNING OBJECTIVES
		INTRODUCTION
		SUBJECTIVE DATA
		OBJECTIVE DATA
		ASSESSMENT
		PLAN
		DOCUMENTATION ERRORS
		EXAMPLES OF SOAP NOTE ORGANIZATION
		SOAP NOTE RUBRIC
		CRITICISMS OF SOAP NOTES
		SUMMARY
		REFERENCE
		Review Exercises
	Chapter 10 What Are Subjective Data and Why Are They Important?
		LEARNING OBJECTIVES
		INTRODUCTION
		SUBJECTIVE DATA
		ORGANIZING SUBJECTIVE DATA
		WRITING SUBJECTIVE DATA
		SUMMARY
		REFERENCE
		Review Exercises
		PRACTICE EXERCISES
	Chapter 11 What Are Objective Data and Why Are They Important?
		LEARNING OBJECTIVES
		INTRODUCTION
		OBJECTIVE DATA
		ORGANIZING OBJECTIVE DATA
		WRITING OBJECTIVE DATA
		SUMMARY
		REFERENCES
		Review Exercises
		PRACTICE EXERCISES
	Chapter 12 What Are Assessment Data and Why Are They Important?
		LEARNING OBJECTIVES
		INTRODUCTION
		ASSESSMENT DATA
		ORGANIZING ASSESSMENT  DATA
		WRITING ASSESSMENT DATA
		INTERPRETATION OF THE DATA IN THE DAILY NOTE
		SUMMARY
		REFERENCES
		Review Exercises
		PRACTICE EXERCISES
	Chapter 13 What Is the Plan and Why Is It Important?
		LEARNING OBJECTIVES
		INTRODUCTION
		TREATMENT PLAN CONTENT
		SUMMARY
		REFERENCES
		Review Exercises
		PRACTICE EXERCISES
PART FOUR Testing What You Know
	Chapter 14 Putting the Pieces Together
		LEARNING OBJECTIVES
		INTRODUCTION
		REVIEW OF THE SOAP NOTE
		AN EXAMPLE OF A COMPLETED SOAP NOTE
		SUMMARY
		REFERENCE
		Review Exercises
		PRACTICE EXERCISES
	Chapter 15 Do You Know Enough?
		LEARNING OBJECTIVES
		INTRODUCTION
		LICENSING EXAMINATION QUESTIONS
		THE PTA’S RESPONSIBILITIES
		LICENSURE REQUIREMENTS FOR PTAs
		TELEREHABILITATION/ TELEHEALTH ISSUES
		SUMMARY
		REFERENCES
		PRACTICE EXERCISES
Bibliography
Glossary
Appendix A Abbreviations
Appendix B Defensible Documentation Elements and Documentation Review Sample Checklist
Appendix C SOAP Note Rubric
Appendix D Documenting Interventions
INDEX