Physical Therapy Documentation

Description

Complete and accurate documentation is one of the most essential skills for a physical therapist to develop and use effectively. Necessary for both new and experienced practitioners, the new and updated Second Edition of Physical Therapy Documentation: From Examination to Outcome will teach and explain physical therapy documentation from A to Z. Physical Therapy Documentation, Second Edition provides individuals with the knowledge and skills for documenting physical therapy services. The text begins with several chapters of background information that give the rationale for quality documentation. Physical Therapy Documentation, Second Edition provides the physical therapist's ethical responsibility for quality record keeping. The mechanics of note writing are delivered in a manner friendly to those who are learning the basic elements of documentation. Mia Erickson, Ralph Utzman, and Rebecca McKnight also include chapters on professional responsibilities and reimbursement issues commonly associated with documentation that are important to physical therapists. Each chapter includes examples and opportunities for practice covering a variety of physical therapy patients and settings.

Features in the Second Edition:

• Multiple sections covering electronic documentation, including the positive and negative aspects and common pitfalls.
• Use of research evidence on integrating and documenting tests and measures is provided in the mechanics of note writing.
• Multiple templates for documenting initial notes, interim notes, and discharge summaries are given but deviation from these templates, such as during use of the electronic record, are also discussed.
• Ethical and regulatory issues related to documentation of physical therapy care.
• Increased emphasis on documenting contemporary concepts such as skilled services and medical necessity. In keeping with the familiarity of the basic SOAP structure, Physical Therapy Documentation, Sec

Table of Contents

Acknowledgments
About the Authors
Preface

Chapter 1: Overview of Disablement
Mia L. Erickson, PT, EdD, CHT, ATC
Chapter 2: Reasons for Documenting in Physical Therapy
Mia L. Erickson, PT, EdD, CHT, ATC
Chapter 3: Ethical and Regulatory Issues in Physical Therapy Documentation
Ralph R. Utzman, PT, MPH, PhD
Chapter 4: Documenting Patient/Client Management: An Overview
Mia L. Erickson, PT, EdD, CHT, ATC and Rebecca McKnight, PT, MS
Chapter 5: Documentation Formats
Mia L. Erickson, PT, EdD, CHT, ATC
Chapter 6: Rules for Writing in Medical Records
Mia L. Erickson, PT, EdD, CHT, ATC
Chapter 7: Documenting Patient Histories and Interviews
Ralph R. Utzman, PT, MPH, PhD
Chapter 8: Documenting Objective Information
Ralph R. Utzman, PT, MPH, PhD and Mia L. Erickson, PT, EdD, CHT, ATC
Chapter 9: Writing the Assessment and the Plan
Mia L. Erickson, PT, EdD, CHT, ATC and Rebecca McKnight, PT, MS
Chapter 10: Interim Documentation
Mia L. Erickson, PT, EdD, CHT, ATC and Rebecca McKnight, PT, MS
Chapter 11: Patient Outcomes and Discharge Summaries
Mia L. Erickson, PT, EdD, CHT, ATC
Chapter 12: Documentation and Reimbursement
Ralph R. Utzman, PT, MPH, PhD

Appendices
Appendix A Guidelines: Physical Therapy Documentation of Patient/Client Management
Appendix B Preferred Practice Patterns
Appendix C Sample Forms
Appendix D Abbreviations and Symbols
Appendix E Assessing Change
Glossary
Financial Disclosures
Index

Authors

Mia L. Erickson, PT, EdD, CHT, ATC is an associate professor and co-Academic Coordinator of Clinical Education in the Division of Physical Therapy at the West Virginia University School of Medicine. Mia holds a Bachelor’s Degree from West Virginia University in Secondary Education and a Master's of Science Degree in Physical Therapy from the University of Indianapolis. She earned her doctor of education degree with emphasis in Curriculum and Instruction from West Virginia University. Her clinical practice is in the area of hand and upper extremity rehabilitation.

Ralph R. Utzman, PT, MPH, PhD is an associate professor and co-Academic Coordinator of Clinical Education in the Division of Physical Therapy at the West Virginia University School of Medicine. He holds a Bachelor's Degree in Physical Therapy and a master’s degree in Public Health from West Virginia University, and a PhD in Health Related Sciences from the MCV Campus of Virginia Commonwealth University. His current clinical practice focuses on patients with vestibular disorders and Parkinson's disease. He teaches in the areas of professional practice roles, practice administration, and clinical skills.

Rebecca McKnight, PT, MS received her Bachelor's of Science degree in Physical Therapy from St. Louis University in 1992 and her post-professional Master's of Science degree from Rocky Mountain University of Health Professions in 1999. Rebecca taught in the Physical Therapist Assistant Program at Ozarks Technical Community College in Springfield, MO from 1997 to 2011. Nine of those years she served as Program Director. Currently Rebecca provides consultation related to curriculum design, development, and assessment through her company Reach Consulting. Rebecca is an active member of the American Physical Therapy Association, primarily within the Education Section.