Writing patient/client notes : ensuring accuracy in documentation / 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.
Preceded by Writing patient/client notes : ensuring accuracy in documentation / Ginge Kettenbach. 4th ed. 2009. Includes bibliographical references and index.
Contents:
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.
This resource is supported by the Institute of Museum and Library Services under the provisions of the Library Services and Technology Act as administered by State Library of Iowa.