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02768aam a2200373 i 4500 001 B020FA18A31D11E69080D5E8DAD10320 003 SILO 005 20161105010102 008 151231s2016 pau b 001 0 eng 010 $a 2015051404 020 $a 0803638205 (pbk) 020 $a 9780803638204 (pbk) 035 $a (OCoLC)934020211 040 $a DNLM/DLC $b eng $e rda $c DLC $d BTCTA $d YDXCP $d NLM $d IOB $d SILO 042 $a pcc 050 00 $a RM701.6 $b .K48 2016 100 1 $a Kettenbach, Ginge, $e author. 245 10 $a Writing patient/client notes : $b ensuring accuracy in documentation / $c Ginge Kettenbach, PhD, PT, Associate Professor, Program in Physical Therapy, Saint Louis University, St. Louis, Missouri, Sarah L. Schlomer, PT, DPT, Adjunct Instructor, Program in Physical Theraphy, Saint Louis University, St. Louis, Missouri,Physical Therapist, SSM Health-Saint Louis University Hospital, St. Louis, Missouri. 250 $a 5th edition. 264 1 $a Philadelphia : $b F.A. Davis Company, $c [2016] 300 $a xiii, 279 pages ; $c 28 cm. 500 $a Preceded by Writing patient/client notes : ensuring accuracy in documentation / Ginge Kettenbach. 4th ed. 2009. 504 $a Includes bibliographical references and index. 505 0 $a Introduction to documentation -- Overview of the health record / Jody Smith -- Legal aspects of the health record / Jody Smith -- Reimbursement / Jody Smith -- Reviewing the health record as a physical therapist -- Writing in a health record -- Introduction to note writing -- Medical terminology -- Using abbreviations -- Introduction to documentation using the ICF System / Sarah L. Schlomer, and Theresa Bernsen -- The patient/client management note : writing history, including the review of systems -- The patient/client management note : writing systems review and tests and measures -- The SOAP note : stating the problem -- The SOAP note : writing subjective (S), including the review of systems worksheet -- The SOAP note: writing objective (O) -- Writing the evaluation -- Writing the diagnosis (A: diagnosis) -- Writing the prognosis (A: prognosis) -- Writing expected outcomes and anticipated goals -- Documenting the intervention plan -- Writing the daily visit note -- The Medicare therapy cap, KX modifiers, and functional limitations reporting (G-codes) -- Applications and variations in note writing. 650 12 $a Medical History Taking. 650 22 $a Physical Therapy Modalities. 650 22 $a Physical Therapy Specialty. 650 22 $a Writing. 655 2 $a Problems and Exercises. 700 1 $a Schlomer, Sarah L., $e author. 941 $a 1 952 $l UUAX975 $d 20161105014915.0 956 $a http://locator.silo.lib.ia.us/search.cgi?index_0=id&term_0=B020FA18A31D11E69080D5E8DAD10320 994 $a C0 $b IOBInitiate Another SILO Locator Search