Includes bibliographical references (pages 222-226) and index.
Contents:
Key aspects of clinical documentation. Disablement models and the ICF framework -- Essentials of documentation -- Legal aspects of documentation / Helene M. Fearon and Stephen M. Levine -- Standardized outcome measures / Julie Fineman and Lori Quinn -- Payment policy and coding / Helene M. Fearon and Stephen M. Levine -- Electronic medical record / Janet Herbold -- Documenting the initial evaluation and beyond : a case-based guide. Clinical decision making and the initial evaluation format -- Documenting reason for referral : health condition and participation -- Documenting activities -- Documenting impairments in body structure and function -- Documenting the assessment : summary and diagnosis -- Developing and documenting effective goals -- Documenting the plan of care -- Session notes and progress notes using a modified SOAP format -- Special formats : screening evaluations, discharge summaries, letters, and patient education materials -- Documentation in pediatrics / Agnes McConlogue and Lori Quinn.
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.