Effective Documentation for Physical Therapy Professionals

TABLE OF CONTENTS

Chapter 1. Introduction, Purpose and General Rules for Health Management (Medical Record Keeping)Chapter 2. Record Organization and General PrinciplesChapter 3. Application of Models for Organization and Guidelines for ContentChapter 4. Component RequirementsChapter 5. Coding and DocumentationChapter 6. Standardized Forms and ContentChapter 7. Legal Issues in the Medical RecordChapter 8. MDS Purpose and ComponentsChapter 9. Medicare and Non-Medicare Content PrinciplesChapter 10. Pediatric DocumentationChapter 11. The Electronic Medical Record or Computerized Patient RecordChapter 12. Utilization Review and Utilization ManagementAppendix A: AbbreviationsAppendix B: CMS 700 FormAppendix C: CMS FOrms 1450 and 1500 with InstructionsAppendix D: ICD-9 Code TermsAppendix E: APTA Guidelines for Physical Therapy Appendix F: Goal Writing ExerciseAppendix G: Note Writing ExerciseAppendix H: Documentation Content ExerciseAppendix I: Physical Therapy Note Examples

AUTHOR PROFILES

Eric Shamus, MS, PT, CSCS has taught national and international continuing education courses on Orthopedics and Sports Medicine, with a focus on documentation and reimbursement. He is presently a professor at Nova Southeastern University, and works at an outpatient orthopedic facility in Fort Lauderdale.

Debra F Stern, PT, MSM, DBA, is an Associate Professor at Nova Southeastern University in Fort Lauderdale, FL. She serves as a clinical instructor with a focus on geriatrics, neuromuscular disorders, and also coordinates service learning experiences for the school's PT department. She received her BS in Physical Therapy from SUNY Buffalo, her MSM from Rollins College, and her DBAS at Nova Southeastern.