Physical Therapy Documentation: From Examination to Outcome

by Mia Erickson, Ralph Utzman, Rebecca McKnight

Overview

Newly updated and revised, Physical Therapy Documentation: From Examination to Outcome, Third Edition provides physical therapy students, educators, and clinicians with essential information on documentation for contemporary physical therapy practice.

Complete and accurate documentation is one of the most essential skills for physical therapists. In this text, authors Mia L. Erickson, Rebecca McKnight, and Ralph Utzman teach the knowledge and skills necessary for correct documentation of physical therapy services, provide guidance for readers in their ethical responsibility to quality record-keeping, and deliver the mechanics of note writing in a friendly, approachable tone.

Featuring the most up-to-date information on proper documentation and using the International Classification of Functioning, Disabilities, and Health (ICF) model as a foundation for terminology, the Third Edition includes expanded examples across a variety of practice settings as well as new chapters on:

• Health informatics
• Electronic medical records
• Rules governing paper and electronic records
• Billing, coding, and outcomes measures

Included with the text are online supplemental materials for faculty use in the classroom.

An invaluable reference in keeping with basic documentation structure, Physical Therapy Documentation: From Examination to Outcome, Third Edition is a necessity for both new and seasoned physical therapy practitioners.

Product Details

ISBN-13:	9781040137024
Publisher:	Taylor & Francis
Publication date:	06/01/2024
Sold by:	Barnes & Noble
Format:	eBook
Pages:	156
File size:	1 MB

About the Author

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.

Table of Contents

Chapter 1: Disablement and Documentation Chapter 2: Reasons for Documenting in Physical Therapy Chapter 3: Ethical, Legal, and Regulatory Issues in Physical Therapy Documentation Chapter 4: Documenting Patient/Client Management: An Overview Chapter 5: Documentation Formats Chapter 6: Health Informatics and Electronic Health Records Chapter 7: Rules for Writing in Medical Records Chapter 8: Documenting the Examination Chapter 9: Documenting the Evaluation Chapter 10: Interim Documentation Chapter 11: Patient Outcomes and Discharge Summaries Chapter 12: Documentation, Insurance, and Payment Abbreviations and Symbols

Editorial Reviews

Reviewer: Jennifer Hoffman, PT, DPT, OCS (Select Rehabilitation)
Description: This update of a 2008 book thoroughly describes how to write various types of physical therapy documentation for the medical record in diverse clinical settings.
Purpose: The purpose is to provide a reference on all aspects of documentation, from taking phone orders in the outpatient setting to writing discharge reports in a skilled nursing facility. The book uses the S.O.A.P. note format and emphasizes documentation of the skilled care services that physical therapists provide in order to maximize reimbursement for therapy services.
Audience: This book is most suitable as a guide to proper documentation for physical therapy students. Experienced therapists will already be well versed in the documentation of various types of notes.
Features: This update briefly covers needed documentation for CMS in the wake of the Affordable Care Act. Its breakdown of the basic S.O.A.P. note format into chapters that discuss each aspect of note writing is useful to students. Flow charts also help clinicians to include all pertinent information in written notes. The book emphasizes the use of outcome measures for goal writing, but does not focus on the components needed to write proper goals. This is evidenced by the lack of emphasis on using functional measures, in addition to outcome measures, in writing long-term goals to develop a more direct treatment plan.
Assessment: This second edition includes an abundant amount of solid, up-to-date information to help aspiring physical therapists or new clinicians write superior S.O.A.P. notes, covering various types of notes in different settings. A bonus for clinicians is a chapter covering documentation and reimbursement including insurance basics, Medicare plans, basic coding, and proper billing using CMS time coding. New therapists will find this invaluable.

Doody's Review Service

This Second Edition includes an abundant amount of solid, up-to-date information to help aspiring physical therapists or new clinicians write superior S.O.A.P notes, covering various types of notes in different settings.  A bonus for clinicians is a chapter covering documentation and reimbursement including insurance basics, Medicare plans, basic coding, and proper billing using CMS time coding.  New therapists will find this invaluable."

- Jennifer C. Hoffman, PT, DPT, OCS, Doody’s Review Service

From the Publisher